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COPYRIGHT DEPOSIT. 



SURGICAL AND 

GYNECOLOGICAL 

NURSING 



BY 

EDWARD MASON PARKER, M.D., F.A.C.S. 

SURGEON TO PROVIDENCE HOSPITAL, WASHINGTON, D. C. 
AND 

SCOTT DUDLEY BRECKINRIDGE, M.D., F.A.C.S. 

GYNECOLOGIST TO PROVIDENCE HOSPITAL, WASHINGTON, D. C. 



WITH 134 ILLUSTRATIONS IN TEXT 




PHILADELPHIA AND LONDON 
J. B. LIPPINCOTT COMPANY 



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COPYRIGHT, I9l6, BY J. B. LIPPINCOTT COMPANY 



. ^ 



Printed by J. B. Lippincott Company 
The Washington Square Press, Philadelphia, U. S. A 



MAR -I 1916 



3)CI.A420976 



Life is short, Art is long, Opportunity fugitive, 
Experimenting dangerous, Reasoning difficult: 
It is necessary not only to do oneself what is 
Right but also to be seconded by the patient, by 
Those who attend him, by external circumstances.' 

Hippocrates — The Aphorisms. 



PREFACE 

The task of preparing a text-book on surgical and gynaeco- 
logical nursing has been approached with considerable hesitation 
and, it is believed, with a full appreciation of the difficulties to 
be encountered and the obstacles to be, if possible, surmounted. 
The responsibility of deciding as to the relative importance to 
the nurse of theory as opposed to practice and the proportion 
of such a book that should be devoted to each has proved no 
light one. Nor has the desire to present all theory from the 
viewpoint of its practical application seemed easy of fulfilment. 

The effort, throughout the preparation of this volume, has 
been to present to the student and graduate nurse an essentially 
practical statement of those procedures in her professional work 
that fall within the realms of general surgery and gynaecology. 
While fully realizing the importance of a clear understanding of 
the theory governing the practice of these branches of nursing, 
it has not appeared either necessary or desirable to attempt the 
incorporation of the theories of the sister branches as presented 
to the student of medicine. As a consequence, such considera- 
tion as may be given to surgical bacteriology, pathology, sympto- 
matology or treatment has been with the sole idea of emphasizing 
the importance of certain nursing duties — as the sterilization of 
instruments and dressings, the accurate noticing and recording 
of signs and symptoms, or the preparation of materials necessary 
for the proper surgical treatment of specified conditions. 

The unusual amount of space (both textual and illustrative) 
given to the subject of surgical instruments was planned with the 
hope that it would give a chance to the nurse for preparation 
before she is thrown into the thick of the operating-room fray. 
Even a general idea of the names, appearances, and uses of the 
instruments she is to handle, together with some knowledge of 
their routine application and order of use, should spare the novice 
at least some part of the discouragement and confusion to which 
she is subject under the operating-room systems of many 
hospitals. 

In addition to those portions of the book that are strictly 
surgical in their application, there has, necessarily, been some 



vi PREFACE 

consideration of border-line subjects. Under this classification 
might come such chapters as the one on the use of fractional 
doses in hypodermic medication and the one upon weights, 
measures, solutions and formulae. The excuse for the presence 
of these particular chapters must be based upon the existence 
of an apparent necessity for the consideration of these subjects — 
particularly in their connection with surgical nursing. 

Throughout, the desire has been constant to prepare a text- 
book that would supply those needs that were most apparent 
to the lecturer and the operator, without neglecting that part 
of the field that had already been fully and successfully covered. 
It only remains to be hoped that the completed volume will, to 
some extent, fulfil this wish. 

Many thanks are due to Captain Christie, Medical Corps, 
U. S. A., and to Sergeant Cahill, of the Army Hospital Corps, 
for assistance with the illustrations of instruments; to Lenz & 
Lossau for the loan of surgical instruments ; to the Superintendent 
of Nurses at Providence Hospital for valuable suggestions and 
aid ; to Mr. William Kearny Carr for the privilege of using some 
of his beautiful microphotographs of bacteria; and to Dr. R. M. 
Le Comte for the loan of a number of examples of the work of 
that past-master of microphotography, the late Dr. William M. 
Gray. Undoubtedly our greatest single obligation is to Miss 
Isabel M. Stewart, of Teachers' College, Columbia University, 
who has reviewed the entire manuscript, and whose criticisms 
and suggestions have pointed the way to a rather thorough 
revision both of the subject matter and arrangement of the book 
to its very great advantage. Our thanks are particularly due 
also to Dr. George W. Crile for his kindness in reading and criti- 
cising the chapter on anoci-association. Finally we desire to 
express our grateful appreciation to the J. B. Lippincott Company 
for their constant courtesy and forbearance throughout a some- 
what tedious siege. 

Edward M. Parker, 

Washington DC, SCOTT D. BRECKINRIDGE. 

December, 1915. 



CONTENTS 

PART I 
INFECTION 

HAPTER PAGE 

I. The Cells of the Body and the Invading Cells 3 

Historical Introduction. The Cell: Form and Structure; Activi- 
ties; Vital Requirements — Moisture, Food, Temperature; Qual- 
ities of the Cell — Irritability, Adaptability, Specialization, Con- 
stant Change, Continuity of Life, Stability. Single-celled Organ- 
isms. Many-celled Organisms. Health and Disease. Infection. 
Single-celled Organisms Concerned in Infection: Bacteria; Pro- 
tozoa; Yeasts and Moulds; Filterable Viruses, Unknown Invaders. 

II. The Sources and Modes of Infection 25 

Number of Species Concerned. Distribution: In Air; in Water; 
in the Soil; in Food; in the Human Body. Relation of Parasite 
to Host. Carriers of Disease Organisms. Modes of Transmission. 

III. Infection in Wounds 34 

Definitions. Operative Wounds. Normal Healing. Infected 
Wounds. Healing in Infected Wounds. Sources and Modes of 
Septic Wound Infection. Bacteria Concerned in Wound Infec- 
tion: Staphylococcus Pyogenes Aureus; Streptococcus Pyogenes; 
Colon Bacillus; Bacillus Pyocyaneus. Other Infections of Im- 
portance in Surgery: Tetanus; Gas Bacillus; Tubercle Bacillus; 
Organism of Syphilis; Gonococcus. 

PART II 
THE FIELD OF SURGERY 

IV. Surgical Pathology 55 

Definitions: Affection; Disease; Etiology; Lesion; Symptom; 
Physical Signs; Signs; Diagnosis; Treatment; Pathology. Mean- 
ing of Pathological Changes. Causes of Disease: Mechanical; 
Physical; Chemical. Changes in Cell Activities: Adaptive 
Changes — Examples of Adaptive Changes, Compensatory 
Changes, Primary Adaptive Changes Which Occur in Accidental 
and Operative Wounds, Inflammation, The Healing Process, 
Healing by Granulation, Defences of the Body Against Infec- 
tion; Perverted Cell Activities. Tissue Changes: Constructive — 
Repair, Hypertrophy, Tumor Formation; Destructive Tissue 
Changes — Atrophy, Necrosis; Cell Degenerations. Disturbances 
of General Function. 

vii 



viii CONTENTS 

V. Surgical and Gynecological Nomenclature 83 

General Derivation; Method of Construction; Root-words; 
Prefixes; Suffixes; Abbreviations. 

VI. The Surgical Field 89 

Outline of the Surgical Field: Affections Not Caused by Disease 
— Anatomical Defects, Mechanical Derangements, Foreign 
Bodies, Trauma; Diseases and Affections Arising from Disease — 
Infections, New-growths, Other Organic Diseases, Functional 
Diseases. Surgical Specialism: Ophthalmology; Otology; Laryn- 
gology and Rhinology; Gynaecology; 'Genito-urinary Surgery; 
Orthopaedic Surgery; Surgery of the Nervous System; General 
Surger} r . Operative Surgery: Nomenclature; Operative Hazards; 
Mortality; Morbidity; The Surgical Obligation. 

PART III 

MINOR TECHNIC IN SURGICAL NURSING 

VII. Postures 101 

The Horizontal Recumbent Position; Trendelenburg Position; 
Reversed Trendelenburg Position; Dorsal Position; Dorsal Ele- 
vated Position; Dorsosacral (Lithotomy) Position; Elevated 
Dorsosacral Position; Right and Left Lateral-prone Position; 
Knee-chest Position; Erect Position. Variations from the Usual 
Arrangement and Equipment in Operations: Trendelenburg; 
Lithotomy; Knee-chest Position. 

VIII. Bandaging 109 

Principles of Bandaging: Those That Concern Efficiency; 
Those That Concern Neatness. Forms and Uses of Bandages. 
Materials and Preparation. Application of the Roller Bandage. 
Bandaging for the Fixation of Dressings. Bandaging for Pres- 
sure. The "Turns" Used in Bandaging. Regional Bandaging: 
The Head, the Neck, the Thorax, the Abdomen, the Extremities. 
Plaster- of-Paris Bandages and Casts. 

IX. Preparation for the Treatment of Fractures 134 

Treatment of Fractures; Fracture Bed; Splints; Padding Splints; 
Materials for Fastening Splints; Apparatus for Extension; Tem- 
porary Fixation of Fractures; Permanent Fixation of Fractures; 
Observation after the Dressing of Fractures. 

X. Remedial Measures 142 

Measures Requiring Simple Cleanliness: The Enema; Rectal 
Irrigation; Continuous Proctoclysis; Active and Passive Conges- 
tion; Continuous Irrigation; Fowler Position; Special Forms of 
Dressings. Routine Measures Requiring Aseptic Technic: Hypo- 



CONTENTS ix 

dermic Medication; Catheterization; Bladder Irrigation; Vaginal 
Douche; Changing of Perineal Dressings. Aseptic Ward Measures 
in Which the Nurse Prepares and Assists: The Dressing Room; 
the Dressing Cart; Dressing of Abdominal Wounds; Hypodermoc- 
lysis; Intravenous Infusion of Physiological Salt Solution; Uterine 
and Vaginal Packing. 

XI. Fkactional Doses in Hypodermic Medication 161 

Method of Obtaining Fractional Doses from a Stock Tablet. 
Table of Fractional Doses from Stock Tablets. General Rules. 
Standard Stock Tablets. Examples. 

XII. Weights, Measures, Solutions and Formula 169 

Weights and Measures: Linear Measure; Measures of Volume; 
Measures of Weight; Transposition of Tables. Solutions. For- 
mulae: For Local Anaesthetics; for Antiseptic Solutions; for 
Enemata; for Saline Solutions; for Ointments and Pastes; for 
Vaginal Douches; for Depilatory Powder. Making Solutions 
from Pure Drugs. Making Solutions from Stock Solutions. 

XIII. Charts and Records 180 

The Chart: Cover Sheet; Temperature Sheet; Record Sheet; 
Medicine and Treatment Sheet. 



PART IV * 
THE PATIENT 

XIV. Observation 189 

The Nurse as an Observer. The Meaning of Observation. 
Method in Observation. The Significance of Symptoms. Con- 
ditions Which Require That the Surgeon Should be Called. 
Objective Symptoms and Signs. Subjective Symptoms: Those 
Connected with the Special Senses; Pain; Organic Sensations; 
Feelings. Measurements and Quantitative Estimations: Meas- 
urement, Quantitative Estimation, the Scale of Seven; the 
Record. 

XV. Measures for the Comfort and Well-being of the Patient 201 
The Work Done by the Nurse Without General or Special Orders. 
Position in Bed. Application of Heat and Cold. Measures 
for Relief of Pain. Water and Food. Attention to Bandages 
and Dressings. Precautions in Acutely Infected Cases : For the 
Patient; for the Household or Other Patients; for the Nurse. 



x CONTENTS 

XVI. Routine Nursing in Operative Cases 213 

Preparation of the Patient for Operation: Bowel Function; 
Diet ; Field of Operation. Routine Treatment after Operation : 
Minor Steps for Comfort of the Patient; Administration of 
Water; Nourishment; Bladder Function; Bowel Function; 
Opiates; Dressings; Sitting Up; Going Home; Belts, Binders 
and Supports. 

XVII. Post-operative Complications 222 

Shock. Hemorrhage. Acute Dilatation of the Stomach. 
Intestinal Obstruction. Infections: Local Infections; Sa- 
praemia; Peritonitis; Septicaemia; Pyaemia; Pulmonary Com- 
plications: Lobar Pneumonia; Bronchopneumonia. Urinary 
System: Retention of Urine; Retention with Overflow; 
Incontinence of Urine; Suppression of Urine. 

XVIII. Anoci-association 229 

Shock and Fear. The Technic of Anoci-association. The 
Nurse's Part in the Anoci-association Technic. 

PART V 
THE OPERATION 

XIX. The Operating Room, its Outfit and Supplies 243 

Organization. The Operating Suite. Fixtures: Sterilizers — 
Hot-air Sterilizer, Autoclave, Instrument Sterilizer, Utensil 
Sterilizer, Water Sterilizers. Operating-room Furniture. 
Supplies. 

XX. Operating Material 261 

Classification. Materials Which Come into Temporary Con- 
tact with the Wound. Materials Which are to Remain in the 
Wound for a Time or Permanently: Method of Preparing 
Catgut Sutures and Ligatures. Materials for Fixation of 
Wound Dressings. Methods of Assembling and Sterilizing 
Operating Material. 

XXI. Surgical Instruments 278 

Cutting Instruments; Clamping Instruments; Holding Instru- 
ments; Exposing Instruments; Sewing Instruments; Auxiliary 
Instruments; Care of Instruments. 

XXII. The Aseptic Technic 296 

Definitions. First Principles of Asepsis. Sterilization by 
Heat. Outlines of the Aseptic Technic: Methods of Sterili- 
zation; Assembling and Handling the Sterilized Outfit; Prep- 
aration of Members of the Clean Group; Conduct During the 
Operation; Conduct Between Operations. The Super-technic. 
Breaks in the Aseptic Technic. 



CONTENTS xi 

XXIII. Preparation for an Operation and the Operating- 
room Personnel 311 

Necessary Preparations — For the Patient, for the Anaesthe- 
tist, for the Operator and Assistants, for the Scrubbed Nurses, 
for the Unscrubbed Nurse. Preparation of the Nurse: Cap, 
Scrub, Gown and Gloves. The Operating-room Personnel: 
Anaesthetist; the Operator; the First Assistant; the Second 
Assistant; the Nurse in Charge of the Instruments; the 
Nurse in Charge of the Sponges; the Unscrubbed Nurse; 
the Orderly. Duties of Operating-room Nurses: The Un- 
scrubbed Nurse; Instrument and Suture Nurse; Sponge 
Nurse. Care of the Anaesthetized Patient. Application of 
the First Dressing. Care of the Patient after Operation. 

XXIV. Selection of Instruments 323 

The Dissecting Set; General Abdominal Set; Appendix Set; 
Gall-bladder Set; Stomach and Intestine Set; Kidney Set; 
Pelvic Set; Hernia Set; Extensive Dissecting Set; Rectal 
Set — For Hemorrhoids, for Fissure or Fistula in Ano, for 
Resection; Female Perineal Set; Uterine Curettage Set; 
Trachelorrhaphy Set; Perineal Prostatectomy Set; Cranial 
Set; Amputation Set. Wiring or Plating Set; Resection Set; 
Osteomyelitis Set. 

XXV. Operative Steps 336 

Operations upon the Head: Trephining; Craniotomy. 
Operations upon the Trunk: Resection of Rib; Gall-bladder 
Operations; Appendectomy; Radical Cure of Inguinal Hernia; 
Shortening of Round Ligaments; Hysterectomy; Dilatation 
and Curettage of Uterus; Trachelorrhaphy; Perineorrhaphy. 
Operations upon the Extremities : Amputation Through the 
Thigh; Disarticulation at the Shoulder. 

XXVI. Operations in Private Houses 345 

The Room; the Table; Utensils and Supplementary Supplies; 
Artificial Light; Substitutes for Lithotomy Posts; Kelly Pad; 
Anaesthetic; Sterilization of Instruments, Water, etc. 

PART VI 

SUPPLEMENTARY CHAPTERS 

XXVII. Gynaecological Dispensary 351 

Records; Examining and Treatment Room; Instruments; 
Preparation for Examination; Drugs, Solutions, etc.; Draping 
of Patient for Examination. 



xii CONTENTS 

XXVIII. Emergencies 356 

Accidents. Wounds. Burns. Fractures: Compound; 
Simple; Fractures at the Wrist; of the Forearm; at the 
Elbow- joint; of the Upper Arm and of the Clavicle; of the 
Leg, Ankle and Foot; of the Thigh; of the Jaw; of the Ribs; 
Dislocation; Injuries of the Knee; of the Ankle; of the Hip. 
Diagnosis of Injuries. Transportation of Patients. Hemor- 
rhage: Methods of Controlling Hemorrhage — Elevation, 
Digital Compression, Flexion, the Tourniquet, Pressure by 
a Bandage, Packing the Wound, Direct Pressure, Heat and 
Cold, Styptic or Astringent Drugs; Indications for the Con- 
trol of Hemorrhage According to Character and Location. 
Artificial Respiration. Shock in Accident Cases. 

XXIX. The Personal Attitude of the Nurse 372 

Attitude to the Patient. Attitude to the Surgeon. Attitude 
to the Hospital. Attitude to the Public. Attitude to Self. 

XXX. An Epitome of Some Common Surgical and Gynaeco- 
logical Conditions 377 

Congenital Deformities and Defects : Cleft Palate and Hare- 
lip; Spina Bifida; Other Congenital Defects. Acquired De- 
formities. Foreign Bodies. Trauma: Definition; Lesions; 
Symptoms and Signs; Wounds of Special Structures; Treat- 
ment. Surgical Infections: Sepsis. Septic Diseases: Ery- 
sipelas; Phlegmon; Abscess; Sepsis in Bone, in Joints, in 
Serous Cavities. Treatment and Nursing. Surgical Tuber- 
culosis. Tetanus. New-growths: Classification; Benign 
Tumors; Malignant Tumors; Tumors in Special Tissues. 
Other Organic Diseases: Goitre; Aneurism; Gangrene. 
Diseases of the Abdomen; Ulcer of the Stomach and Duo- 
denum; Cancer of the Stomach and Intestines; Appendicitis; 
Intestinal Obstruction; Tuberculous Peritonitis; Hernia; Gall- 
stone Disease. Gynaecological Diseases: Malformations and 
Displacements; Atresia of the Vagina; Anteflexion of the 
Uterus; Retroversion of Uterus; Prolapse of Uterus. Injuries : 
Laceration of Cervix; Laceration of Perineum. Inflamma- 
tions: Vulvitis; Endometritis; Salpingitis. New-growths: 
Ovarian Cysts; Fibroid Tumors of the Uterus; Cancer of 
the Uterus. 



ILLUSTRATIONS 



PAGE 



1. Diagram of a Cell 9 

2. Multiplication of a Cell (Craig) 10 

3. Showing Relative Size of Bacteria 19 

4. Diphtheria Bacilli (Carr) 20 

5. Spirilli of Asiatic Cholera (Carr) 20 

6. Bacillus Subtilis, Showing Flagellar (Gray) 21 

7. Diplococcus Pneumoniae (Carr) 21 

8. Streptococci (Gray) 21 

9. Staphylococci (Carr) 21 

10. Bacilli Showing Spores (Parker) 21 

11. Chart Showing Normal Temperature After Operation 38 

12. Chart Showing Traumatic Temperature (Miss Kathleen Carroll) . . 39 

13. Chart Showing Septic Infection (Local Abscess) After Operation. . . 40 

14. Chart Showing Septic Infection, Continued Type (Miss Emily 

Warren) 43 

15. Staphylococcus Pyogenes (Carr) 47 

16. Streptococcus Pyogenes (Parker) 47 

17. Bacillus Coli Communis, Showing Flagellar (Gray) 48 

18. Bacillus Pyocyaneus, Showing Flagellar (Gray) 48 

19. Bacillus Tetani, Showing Flagellse (Gray) 49 

20. Bacillus Tetani, Showing Spores (Carr) 49 

21. The Gas Bacillus (Parker) 50 

22. Tubercle Bacilli (Carr) 50 

23. Treponema Pallidum (Gray) 51 

24. Micrococcus Gonorrhoeae (Wood) 52 

25. Frog's Mesentery, Normal (Agnew) 68 

26. Frog's Mesentery, Inflamed (Agnew) 68 

27. Emigration of Leucocytes (Wood) 69 

28. Section Through Skin of Guinea-pig Eight Hours After a Wound 

(Shakespeare) 70 

29. Same at Later Stage (Shakespeare) 71 

30. The Same Later (Shakespeare) 72 

31. Cicatrix Formed in the Wound (Shakespeare) 73 

32. Healing of a Wound by Granulation (Wood) 74 

33. Varieties of Blood-cells 75 

34. Amoeba Coli (Entamoeba Dysenteriae), Common Form 75 

35. Phagocytosis (Wood) 77 

36. Horizontal Recumbent Position 102 

37. Trendelenburg Position 102 

38. Dorsal Position 103 

39. Dorsosacral (Lithotomy) Position 104 

40. Right Lateral-prone Position 105 

41. Genu-pectoral (Knee-chest) Position 106 

42. Triangular Bandage (Eliason's Practical Bandaging) Ill 

xiii 



xiv ILLUSTRATIONS 

43. Single T-Bandage Ill 

44. Four-tailed Bandage Ill 

45. Modified Bandage of Scultetus 112 

46. Rolling Bandage by Hand 113 

47. Bandage Roller 114 

48. Circular Turns of a Bandage (Eliason's Practical Bandaging) 118 

49. Spiral and Oblique Turns (Eliason's Practical Bandaging) 119 

50. Making Reverses 120 

51. Figure-of-Eight Turns (Eliason's Practical Bandaging 121 

52. Spica of the Hip 122 

53. Recurrent of the Scalp (Eliason's Practical Bandaging) 122 

54. Recurrent Bandage of the Stump 122 

55. Recurrent Turns (Eliason's Practical Bandaging) 123 

56. Figure-of-Eight of the Head and Neck (Eliason's Practical Ban- 

daging) 123 

57. Double Oblique of the Jaw (Eliason's Practical Bandaging) 123 

58. Four-tailed Bandage of the Chin (Eliason's Practical Bandaging) . . 123 

59. Barton's Bandage 124 

60. Gibson Bandage (Eliason's Practical Bandaging) 124 

61. Spiral Reverse of Lower Extremity (Eliason's Practical Bandaging) 126 

62. Velpeau Modified (Dulles) (Eliason's Practical Bandaging) 127 

63. Desault Bandage (Eliason's Practical Bandaging) 128 

64. Finger Bandage 129 

65. Spica of the Foot (Eliason's Practical Bandaging) 129 

66. Method of Squeezing Water from Bandage (Eliason's Practical 

Bandaging) 131 

67. Making Plaster Bandages (Eliason's Practical Bandaging) 131 

68. Instruments for Removing Plaster Casts (Eliason's Practical Ban- 

daging) 132 

69. Buck's Extension . (Eliason's Practical Bandaging) 139 

70. Dressing for Fracture of Shaft of Femur. 139 

71. Median Section of Female Pelvis 143 

72. Apparatus for Proctoclysis 147 

73. Showing Notch Filed in Stop-cock 148 

74. Taped Adhesive Strips 158 

75. Chart Showing Morning and Evening Temperature (Septic Perito- 

nitis) 181 

76. Four-hour Chart (Septicopyemia) 182 

77. Type of Record Sheet 183 

78. Medicine and Treatment Sheet 185 

79. Operating Room 245 

80. Sterilizing Room 246 

81. Hot-Air Sterilizer 247 

82. Autoclave 248 

83. Autoclave with Drums for Dressings 249 

84. Instrument Sterilizer 250 

85. Utensil Sterilizer 251 

86. Water Sterilizers 252 



ILLUSTRATIONS xv 

87. Operating Table 253 

88. Drums on Stand 254 

89. Irrigator Stand 255 

90. Needle and Thread for Arterial Suture (Bernheim) 276 

91. Flask for Arterial Sutures 276 

92. Cutting Instruments: Knives and Scissors 279 

93. Cutting Instruments : Bone Drills and Trephines . . .' 280 

94. Cutting Instruments: Curettes 280 

95. Cutting Instruments: Bone Cutters 281 

96. Cutting Instruments: Chisels and Gouges 281 

97. Cutting Instruments: Bone Saws 282 

98. Clamping Instruments: Haemostatic 284 

99. Clamping Instruments 284 

100. Clamping Instruments 284 

101. Clamping Instruments: Intestinal Clamps 284 

102. Holding Instruments 285 

103. Holding Instruments 285 

104. Exposing Instruments: Retractors 286 

105. Exposing Instruments: Retractors 287 

106. Exposing Instruments: Retractors 287 

107. Exposing Instruments: Specula 288 

108. Exposing Instruments: Specula (Vaginal) 288 

109. Surgical Needles 289 

110. Needle Holders 291 

111. Sewing Instruments: Ligature and Suture Carriers 291 

112. Auxiliary Instruments: Probes, Directors, Dissectors 292 

113. Auxiliary Instruments: Dilators 292 

114. Auxiliary Instruments: Dilators 294 

115. Auxiliary Instruments: Evacuators (Catheters) 294 

116. Auxiliary Instruments: Evacuators (Trocars and Cannula?) 294 

117. Diagram of Arrangement of Operating Room 316 

118. Showing Improper Position of Arm 320 

119. Pillow Support Under Back 321 

120. Instruments: the Dissecting Set 324 

121. Additions for General Abdominal Set 324 

122. Additions for Gall-Bladder Set * 326 

123. Additions for Pelvic Set 326 

124. Additions for Hemorrhoid Set 328 

125. Additions for Female Perineal Set 328 

126. Uterine Curettage Set 330 

127. Cranial Set 330 

128. Bone and Cranial Set 332 

129. Amputation Set 332 

130. Joint Resection Set 333 

131. Rib Resection Set 334 

132. Osteomyelitis Set 334 

133. Shafer Method of Artificial Respiration, First Position 370 

134. Shafer Method of Artificial Respiration, Second Position 370 



PART I— INFECTION 



SURGICAL AND 
GYNECOLOGICAL NURSING 

CHAPTER I 
THE CELLS OF THE BODY AND THE INVADING CELLS 

Modern surgery may be said to owe the whole of its wonder- 
ful advancement to the invention of a single instrument, the 
purpose and uses of which were so far removed from the obvious 
needs of the surgeon that not the wildest dreamer could have 
guessed its epoch-making importance in relation to surgical 
practice. The immensely widened field of vision which the 
microscope opened up to the students of living matter resulted 
finally, among many other benefits, in freeing surgery from the 
terrible handicap of wound infection under which it had labored 
for more than a score of centuries. Under this handicap surgical 
operations which are now considered trivial and practically 
devoid of risk, were attended with a huge mortality, and almost 
every form of operative interference involving the deeper parts 
of the body was absolutely prohibited by death in practically 
all the cases. All the great serous cavities of the body were thus 
placed beyond the possibility of surgical exploration. Abdomi- 
nal surgery was an almost untouched field, surgical manipulation 
within the thoracic or cranial cavities undreamed of. Trephining 
the skull was a very ancient operation, it is true, but only the 
boldest surgeon ever ventured to cut through the lining mem- 
brane of the cranium which encloses the brain, and none dared 
repeat the venture often. John Hunter, greatest English surgeon 
of his time, declared that he never saw a case recover where the 
dura mater had been either wounded or incised at an operation. 
Even in the more external parts of the body wounds, whether 
operative or accidental, except the most trivial, resulted in a 
dreadful proportion of fatalities. The amputation of limbs, even 

3 



4 INFECTION 

in the most skilful hands, had a mortality of forty per cent, or 
more. Of compound fractures of the thigh treated during the 
Napoleonic wars over eighty per cent, were fatal. The menace 
of septic disease in wounds naturally increased in proportion as 
patients were brought together in large hospitals, so that the 
very circumstance which would otherwise have favored progress, 
by giving to the surgeon the advantage of an enlarged experience, 
became the means of retarding every effort at improvement in 
operative work by the almost prohibitive death rate which it 
imposed. 

The emancipation of surgery from the bonds which had so 
long confined it began with the work of Joseph Lister, following 
the lead of the great Frenchman. Louis Pasteur. The time was 
peculiarly ripe for the triumph which Lister was destined to 
achieve. Anaesthesia by means of ether and chloroform had 
been discovered and had now been an established procedure in 
surgical practice for more than a decade. To make clear the 
full meaning of this innovation it is necessary to point out that 
its benefits were of two kinds. The ' 'Death of Pain," inestimable 
boon though it was for the patient, was of far less importance 
from the larger outlook than the opportunity now given to the 
surgeon of doing his work with deliberate care. In pre-anaes- 
thetic days surgical operations had to be done at the highest 
attainable speed. Two or three minutes, for example, was the 
record for an amputation which every surgeon strove to equal 
or surpass. With the introduction of anaesthesia all this was 
changed. Hours instead of minutes were now available if neces- 
sary. The dexterity of the juggler ceased to be the ideal for the 
work of an operating surgeon, and the painstaking skill of an 
expert handicraftsman took its place. As a consequence the 
temptation to try out improved methods and new operation- 
was almost irresistible, and surgeons everywhere were pressing 
restlessly against the limitations which the huge mortalities 
from sepsis still imposed upon them. A quarter of a century 
earlier a great German anatomist had been the first to formulate 
clearly the theory of a living contagion: our own Dr. Oliver 
Wendell Holmes had pointed out the contagious nature of puer- 
peral fever, and had suggested the employment of chemical dis- 
infectants as a safeguard against it: in the obstetric wards of a 
great hospital in Vienna such measures had been put to the test 
of practical use with marked success; but because the time was 



CELLS OF BODY AND INVADING CELLS 5 

unpropitious the voices of these pioneers had fallen on deaf ears, 
and to Joseph Lister was to belong the honor of leading the way 
in the greatest forward step that had been made since surgery 
began. 

The early investigations of Pasteur had shown that the 
familiar phenomena of fermentation and putrefaction were in 
reality due to the action of minute living organisms which the 
microscope had made visible, and the character of the foul dis- 
charges from inflamed wounds, so like the putrefactive process, 
suggested to Lister the possibility of a similar causation. The 
case as regards fractures was particularly suggestive of this. It 
was a commonplace that simple fractures, i.e., where the skin 
was unbroken, healed without inflammation, fever or any foul 
discharge, and practically all these cases recovered. In compound 
fractures, on the other hand, i.e., where an open wound communi- 
cated with the broken bones, the putrefaction-like process of 
suppuration accompanied with inflammation and fever invariably 
occurred, and the majority of these patients died. In Lister's 
mind it was a clear inference that the difference in these two cases 
was due to the entrance into the wound of living germs from the 
air, and he acted on this idea. Carbolic acid was already known 
as an efficient preventive of putrefaction, and in August, 1865, 
Lister first applied a carbolic dressing to the wound of a compound 
fracture. The result was all that he had hoped. No suppuration 
occurred. A scab formed over the wound and the case progressed 
to recovery like a simple fracture. Other similar results followed, 
and he was encouraged to extend the application of what he 
called "the antiseptic principle in surgery" to other accidental 
wounds and also to operative wounds with equal success. Still 
possessed by the natural but mistaken idea that the air was the 
source from which the dangerous organisms came, he began to 
perform his operations under a cloud of spray impregnated with 
carbolic vapor formed by a steam nebulizer. Instruments were 
smeared with carbolic oil, hands, sponges, ligatures and dressings 
dipped into carbolic solution. These methods were crude in the 
light of later developments, but they sufficed. 

The new principle in surgery thus inaugurated was naturally 
not accepted all at once or without controversy, but Lister's 
mind was of too fine a temper to be discouraged by opposition 
or embittered by hostile criticism. He pressed on, constantly 
improving his methods, and his results soon accumulated a weight 



6 INFECTION 

of evidence that compelled recognition from his doubting col- 
leagues. Even the most determined opponents of his theory 
unconsciously modified their own technic in accordance with 
the new idea, and in proportion as they did this were rewarded 
with improved results. Lister's investigations, however, were 
confined almost entirely to the practical side of the problem. He 
spoke vaguely of putrefaction in wounds resulting from the pres- 
ence of living organisms, and the question as to the exact nature 
and life history of these organisms remained unanswered. His 
work, therefore, convincing as it was, lacked the completeness 
and precision of a scientific demonstration and it was reserved, 
as perhaps might have been expected, for the patient and exact 
methods so characteristic of German science to attain this goal. 

A year after Lister's first experiment there was graduated 
from a Prussian university a young student in medicine who 
was destined to play a leading part in investigating the relation 
of microorganisms to infectious disease. Robert Koch began 
his studies of these organisms during the leisure moments that 
could be spared from a laborious country practice. The work 
which he did under these circumstances, judged in the light of 
its results, may be regarded as one of the most brilliant achieve- 
ments of any scientific worker of modern times. The methods 
which he devised for manipulating, staining and cultivating 
bacteria, with the results of his investigations by means of these 
methods, brought him almost from the moment of their announce- 
ment a leading position among German scientists and made him 
virtually the founder of the science of bacteriology. The new 
science, attracting a host of eager workers, at once entered upon 
an amazingly rapid development, and in a few years the vague 
general ideas previously held had given place to a large fund of 
exact knowledge concerning the life history of many individual 
species of bacteria and their relation to communicable diseases, 
including the surgical infections. Koch himself, ten years after 
the publication of Lister's first paper, was able to give to the 
world a full account of some half-dozen species concerned in the 
traumatic infections in animals and man. 

The methods of wound treatment and the technic at opera- 
tions designed to prevent infection, which Lister's earlier experi- 
ments introduced, were crude indeed compared with those in use 
at the present time, but while nature holds us to strict account 
for disobedience to her laws she often rewards us generously, 



CELLS OF BODY AND INVADING CELLS 7 

even lavishly, for only a partial understanding of her secrets. 
It was so now. As Lister's methods began to come into general 
use suppuration in wounds became less and less frequent. Large 
mortalities dropped to small and in some cases even to negligible 
figures. Healing "by first intention," so-called from the time of 
Hippocrates, i.e., healing without inflammation or suppuration, 
ceased to be a surgical curiosity and began to be called normal 
healing. The awful scourge of hospital gangrene, so common up 
to Lister's time, vanished utterly. 

The result of Lister's work for surgery may be likened to 
the setting free of a lifelong captive from a dark and narrow 
prison. The strong doors, barred and guarded for so many ages, 
were now, almost suddenly, thrown wide open. Surgeons, grop- 
ing forward in an unaccustomed freedom, many of them hardly 
realizing what had happened, began to find that they could now 
do many things safely that had always been prohibited. Con- 
stant improvements in technic opened the way for new suc- 
cesses. The gradual recognition of the fact that the entrance 
of bacteria into wounds occurs practically always by contact 
with material things to which these organisms adhere (hands, 
instruments, ligatures, dressings), while infection through the air 
is negligible; the introduction, first in Koch's laboratory, of 
sterilization by high -pressure steam; and the use of rubber gloves 
for the hands of the surgeon and his assistants, first practised 
by Halsted at the Johns Hopkins Hospital, revolutionized the 
earlier methods of preventing infection in operative wounds, 
inaugurating the present or what is known as the " aseptic" era, 
in contradistinction to the " antiseptic" era of early Listerian 
practice, and enabled surgeons to perform the most extensive 
operations in all the formerly forbidden regions of the body with 
an almost mathematical certainty that no infection would follow 
and that normal healing would be secured. The way was thus 
opened for the immense development of operative surgery which 
in the past fifty years has been many times greater than in all 
the preceding centuries. There were many new difficulties to 
be overcome and dangers to be encountered, but the difference 
was that under the old conditions these problems could not be 
approached at all; now the path was clear. 

Among the many changes which the new era, resulting from 
these discoveries, has brought about, not the least in importance 
is concerned with surgical nursing. The time has long passed 



8 INFECTION 

when a surgical operation was the work of one man with the 
assistance of one or two unskilled helpers. Success under modern 
conditions requires the coordinated efforts of a highly trained 
and perfectly organized team of workers. The aseptic surgical 
technic, that elaborate system which has been gradually worked 
out, whose object is to prevent the occurrence of infection in 
wounds, demands not only the strict observance of proper 
methods at the operation itself, but also expert knowledge and 
conscientious exactness in all the details of preparation. This 
work of preparation calls for its own separate organization, with 
an elaborate equipment of technical apparatus requiring special 
skill in its use, and the responsibility for this rests almost wholly 
upon the shoulders of the surgical nurse. It is highly important 
that the carrying out of this part of the work should depend, 
not upon the blind observance of a set of rules, vaguely under- 
stood and often imperfectly remembered, but rather upon an 
intelligent application of clearly comprehended principles, based 
upon a correct knowledge of the conditions under which wound 
infection takes place. Before entering, therefore, upon the prac- 
tical side of our presentation of the technical duties involved in 
surgical and gynaecological nursing, it is necessary to devote some 
space to a consideration of the infection problem, the life history 
and distribution of the living organisms concerned, and the 
relation of these organisms to infectious disease. 

I. THE CELL 

1. The Cell as the Unit of Living Matter. — To understand 
the meaning of infection we must begin with the study of the 
cell. When plant tissues were first examined under the micro- 
scope they appeared to be made up of an aggregation of tiny 
hollow chambers, which, because of their likeness to the structure 
of a honey-comb, were called cells. When on later study it 
became gradually clear that all living matter is made up of very 
small individual structural units, the name "cell" was retained 
for these units, although in most cases they bear no resemblance 
to a hollow chamber. Every living thing, whether plant or 
animal, is composed of cells. The bodies of all the higher animals, 
man included, are built up out of a vast number of cells of many 
kinds, and all the activities of their bodies, of growth, of nutrition, 
of secretion, of movement, or of reproduction, are really the 
activities of the cells which compose them. 



CELLS OF BODY AND INVADING CELLS 



9 



2. Form and Structure of the Cell. — Cells exhibit immense 
variety in size, in form, in structural complexity, and particularly 
in functional activity. A few may be large enough to be visible 
to the naked eye, but most are far too small to be seen without 
the aid of magnifying lenses. In its essential features a cell 
(Fig. 1) consists of a minute globule of matter, the cell body, 
containing in its centre a smaller body called the nucleus. A 
more or less clearly defined membrane, the cell wall, may sur- 
round the body of the cell. When a cell is stained with aniline 
dyes the nucleus takes the stain more strongly than the cell 



Cell wall or limiting 

membrane 



Nuclear membrane 
Nucleus 



Cell substance or 
cytoplasm 




Fig. 1. — Diagram of a cell. 



body and appears clearly and sharply defined, demonstrating 
its difference in chemical composition from the remaining cell 
substance. The nucleus is believed to be the most important 
element in the cell structure. It contains a special substance, 
peculiar to living matter, known as "chromatin" or "chromo- 
plasm," which appears to play the most important role in the 
cell activities. The substance of the cell body is called "cyto- 
plasm." It may be smooth or granular in appearance, and some- 
times has the suggestion of an intracellular network. The con- 
sistence of the cell substance is probably that of a semifluid or 
thin jelly. The solid part of plants and animal bodies are not 
generally regarded as part of the living cell substance, but as 
inert material built up by the chemical activities of the cell. 
Many cells, particularly among the single-celled organisms, have 



10 



INFECTION 



special structural appendages to facilitate their motion or for 
other uses. 

3. The Activities of the Cell: (1) Movement. — Many cells 
have the power of motion by virtue of a contraction of a portion 
of the cell substance in various ways. The movements of single- 
celled organisms and the muscular movements of the higher 
animals are alike due to the exercise of this power. 

(2) Reproduction. — At some period in its life every cell has 
the power of reproduction by dividing itself, usually into two 
daughter cells (Fig. 2), sometimes into many new cells. Over 
this process the nucleus presides through a series of wonderfully 




Fig. 2. — Multiplication by simple division in Entamoeba coli (Craig). This is a single- 
celled organism which is the cause of certain forms of tropical dysentery in man. 

complex changes. Every existing cell has arisen from another 
cell through the exercise of this reproductive power. Each cell 
reproduces only its own kind. 

(3) Chemical Activities. — All cell activities are doubtless 
chemical in nature, but the mature cell does a vast amount of 
work in changing the chemical composition of substances taken 
into its own body and of the material surrounding it. These 
chemical activities appear in: (a) the absorption of suitable 
material from their surroundings to be utilized in their nutrition 
and growth; (6) in oxidation, or the burning up of material with 
the production of heat; (c) secretion, or the formation of new 
chemical compounds which are then extruded from the cell; 
(d) excretion, the casting off of waste material; and (e) what is 
perhaps akin to secretion, the building up of intercellular sub- 
stances which form the solid parts of the structure of animals 
and plants. 

4. The Vital Requirements of the Cell: (1) Moisture. — 
Every living cell must be surrounded with moisture in order to 



CELLS OF BODY AND INVADING CELLS il 

enable it to carry on its chemical activities. All the living cells 
of the human body are bathed in fluid. A scratch upon the 
surface shows how thin is the protecting covering of inert dried 
material by which the fluids are confined. Matter upon which 
the cell acts to produce chemical change must first be brought 
into a state of solution, and a fluid environment is therefore 
necessary to all cell life. 

(2) Food. — Cells require suitable material in their surround- 
ings to be utilized by them for their nutrition and growth and 
for the exercise of their other chemical activities. Some cells 
can go into a resting stage, during which they remain alive, 
although deprived for the time of food and of moisture. Later, 
under favorable conditions of moisture, food supply, and tem- 
perature, they may renew their active life. 

(3) Temperature. — Active cell life is possible only within 
rather narrow limits of heat and cold. For each kind of cell 
there is an " optimum" temperature at which it thrives best. 
At a temperature a few degrees below this all cell activity will 
be checked or cease entirely. At a temperature somewhat 
higher the life of the cell will be destroyed. Some cells in a 
resting stage (such as the spores of certain bacteria) can survive 
extreme degrees of heat, considerably above the boiling point 
of water. Most cells bear exposure to cold rather well. Many of 
the cells of our own bodies can recover from a freezing temperature. 

5. The Characteristics or Qualities of the Cell: (1) Irrita- 
bility. — This means that the activity of a cell can be affected 
by influences from without. Any influence exerted upon a cell 
which causes a change in its activities is called a' "stimulus." 
All the activities of a cell may be affected by a stimulus — its 
nutrition, its secretions, its motion, or its reproductive power; 
and the effect of the stimulus may be manifested in either of 
two ways, by increasing or by diminishing the activity of the 
cell, or, as we say, the effect may be to excite or to inhibit its 
activities. Any external changing condition may act as a stimu- 
lus — mechanical or chemical effects, light, heat, electricity, the 
influence which nerve fibres convey, and so on. Certain condi- 
tions within the body of the cell itself may also act as stimuli, 
such, for example, as its own physiological condition, particularly 
with regard to its supply of nourishment. Thus starvation or 
repletion will affect its activities in different ways. The excited 
activity may continue for a time after the stimulus has ceased 



12 INFECTION 

to act. Repeated stimulation may bring about exhaustion and 
cessation of activity. Repeated stimulation, not of too high 
intensity or too continuous, may develop and increase the cell's 
power of action in some one direction. A high intensity may 
inhibit, while a lower intensity of the same stimulus may excite 
cell activity. When a cell's activity is affected by a stimulus 
it is said to respond or react to the stimulus. The lowest intensity 
of a stimulus which will cause a cell to react is called the "thresh- 
old" for that stimulus. Repeated stimulation may result in 
some cases in cessation of response on the part of the cell or a 
raising of the threshold, a higher intensity being required to 
excite action. The sum total of all the stimuli acting on a cell 
constitute its "environment." 

(2) Adaptability. — That quality of the cell whereby it is 
enabled to respond differently to a stimulus because of previous 
stimulation is of far-reaching significance in the economy of 
nature. Because of this the cell is enabled to adapt itself within 
certain limits to changed conditions in its environment. The 
capacity of the cell to increase its power under stimulation is 
also a factor in the adaptation of the individual cell to changed 
conditions. Moreover, there are always slight differences among 
individual cells of the same kind in regard to their susceptibility 
to certain influences. Under changed conditions, then, some 
cells may perish while others survive, and these may transmit 
their resisting powders to their descendants, giving rise to a 
strain adapted to the new environment. 

(3) Specialization. — In the single-celled organisms and in the 
cells which make up the tissues of animals and plants there is 
an infinite variety in the forms of activity which the cells exhibit. 
No cell is capable of all the forms of activity possible for a cell, 
but each kind of cell specializes in some particular form. Cells 
are specialized not only in their activities but also in being 
adapted to respond to particular kinds of stimuli. Thus, for 
example, certain cells in the retina of the eye are specially adapted 
to respond to light, other cells in the ear to respond to vibrations 
in the air. Any stimulus capable of exciting the special activity 
of a cell is called an adequate stimulus for that cell. A specialized 
cell responds with its own particular form of activity whatever 
the nature of the stimulus. 

(4) Constant Change. — The chemical changes which go on 
within the living cell are exceedingly complex. It is a chemistry 



CELLS OF BODY AND INVADING CELLS 13 

of constant giving up and taking in, special substances capable 
of serving a purpose useful to the organism are formed, and other 
substances are thrown out because they have served their purpose 
and become waste matter. New matter is meanwhile being 
taken in to be built up into living substance in place of the 
material that has been thrown out. The cell is thus ceaselessly 
falling to pieces and rebuilding its own substance. 

(5) Continuity of Life. — In the process of reproduction the 
cell does not die, but passes on its own substance and its living 
activities into two or more daughter cells. Thus cell life is con- 
tinuous and not interrupted by any condition that can be called 
death. Many cells are destroyed, of course, by accident or other- 
wise; and many differentiated cells, having lost the power of 
reproduction, perish when their usefulness is ended, but there 
is a sense in which it may be said that death has no meaning as 
applied to the cell. 

(6) Stability. — The evidences of life upon the earth in remote 
geologic ages, in all essentials like the forms of life now existing, 
give striking proof of the immense stability of the hereditary 
factors in the reproduction of the cell, while the traces of a 
wonderful evolutionary history throughout these ages testify 
with equal force to its powers of adaptation. 

For the solution of all the problems in every department of 
science relating to living things we must seek the final answer 
in the study of these tiny units in the structure of all living 
things. Incessantly disintegrating, yet immortal; more stable 
than continents and oceans, yet infinitely plastic and adaptable; 
the cell, which is the ultimate unit of living matter, serves also 
as the most fitting symbol and expression of the mystery of life. 

II. SINGLE-CELLED ORGANISMS 

By the term organism is meant any individual animal or 
plant which lives a self-sufficient existence and in due course 
reproduces its own kind. Among the lower forms of life there 
are very many organisms which consist of only a single cell. 

These single-celled or unicellular organisms behave in a 
primitive way much like the higher forms. Each cell lives an 
independent existence. They assimilate nourishment, grow, -and 
reproduce their kind; and many of them are able to move about 
by means of active movements of portions of the cell body, or 
through special organs of locomotion, usually by a swimming 



14 INFECTION 

process, for like all cells they require fluid surroundings for their 
active life. 

Unicellular organisms are very abundantly distributed in 
nature. A vast number of different species of them exist, differing 
widely in structure, in their activities, and in the conditions 
under which they thrive. Swarming in countless numbers and 
variety wherever the conditions are favorable for them — in 
water, in soil, as parasites living upon higher organisms, and 
especially wherever there is dead organic matter — these silent, 
invisible living things play a role of incalculable magnitude and 
importance in the happenings of our world. 

III. MANY-CELLED ORGANISMS 

There are no two-, or three-, or few-celled organisms. We pass 
at once from the single-celled forms to those that are composed 
of many cells. These include many forms that are very low in 
the scale, and also, of course, all the higher species of plants and 
animals. In the multicellular organisms the cells do not live a 
separate and self-sufficient existence. They are dependent on 
each other for many of their needs, and their activities are often 
directed for the benefit of the organism as a whole rather than 
solely for their own individual requirements. 

The most striking feature of the higher forms of life, con- 
sidered as an aggregation of cells, is the amazingly perfect organ- 
ization which they exhibit. This organization is manifest both 
in structure and in function. On the structural side we have the 
differentiation of cells into peculiar tissues and the aggregation 
of similar cells into special organs. In the animal body there are 
complex structures for locomotion, for the seizing of food material 
and for its digestion, and others for the purpose of keeping all 
the cells bathed in fluid and for conveying to them the nourish- 
ment that has been prepared for them. There are other organs 
(the special senses) for the reception of stimuli from outside the 
body, so that the behavior of the animal can be modified in ways 
appropriate to its environment. As regards organization in 
function we have a nearly perfect system of control whereby 
all the cell activities of the body are directed for the benefit 
of the whole organism. 

It is the capacity of the cell to respond to a stimulus which 
makes it possible for the higher living organisms to exist, since 
because of it the cells composing the organism can be made to 



CELLS OF BODY AND INVADING CELLS 15 

act in harmony. Our own bodies, for example, are made up of 
an innumerable host of cells whose activities are not haphazard 
or independent, but are obviously marshalled under orderly 
control and discipline. A wonderful division of labor exists 
among them. The muscle cells have given up all their other 
activities, save nutrition, to devote their whole energy to the 
exercise of their contractile power. Epithelial cells cover the body 
surfaces and line the tubes and ducts of the various secreting 
glands where they specialize in the production of different secre- 
tions which are useful to the organism as a whole. The connec- 
tive tissue cells, through thickening of the cell wall and the 
formation of intercellular substances, build up the supporting 
framework of the body, its bones, ligaments, tendons, etc. The 
nerve-cells are organized into a wonderfully complex system for 
the regulation of all the bodily functions and activities. They 
specialize in the reception and coordination of stimuli received 
from sources external to the body, and in the conveying of appro- 
priate stimuli to the cells of the various organs so that they may 
act in harmony for the best interests of the organism as a whole. 

All the structural features of the body, its framework, its 
coverings of skin and mucous membranes, its complex tissues 
and organs, and all their manifold functional activities, are thus 
the result of the work of specialized cells under a marvellously 
complex system of control. 

We do not know what the factors are that determine this 
organization. But it is quite certain that the amount or the 
intensity of the various activities of any cell is determined by the 
stimuli arising from its environment, and in the animal body, for 
example, a large part of this environment consists of conditions 
resulting from the activities of other cells, so that there is an 
amazingly intricate interplay of stimuli between the different 
cells of the organism. There are also adjustments for the rapid 
conveyance of stimuli arising from the activities of one set of 
cells to other cells at a distance, largely through the nervous 
system, but partly also by other means. Thus the responses of 
the cells to external stimuli, to stimuli arising from their own 
physiological condition, and to stimuli arising from the activities 
of other cells, bring about as a resultant an orderly balance and 
harmony in the activities of all the cells, and a condition of the 
body as a whole which we designate as normal or as a condition 
of health. 



16 INFECTION 



IV. HEALTH AND DISEASE 

The word " normal" means conforming to a recognized stand- 
ard; agreeing with an established type, bnt the standard is never 
very exact. Thus in any group of persons each one may be a 
normal individual although differing rather widely in many par- 
ticulars from others in the group. The same is true of the normal 
working of a many-celled organism as represented by the har- 
monious activities of its cellular elements. The normal standard 
for these multitudinous activities is not rigid but extremely 
flexible. A deficiency, whether momentary or continued, of one 
part of the mechanism may be supplemented or compensated for 
in various ways by increased activity in other parts. Thus an 
adjustment of the working of the complex organism to changing 
conditions in its environment is continually going on. Different 
kinds or groups of cells are inevitably subjected from time to 
time to alien stimuli, often in themselves potentially harmful, 
and in such a case the organism must automatically find an answer 
to the problem of adjusting itself to that particular situation. 
This adjustment of the organism to its environment is called 
" adaptation.". It is a commonplace that different living organ- 
isms are adapted to exist in very various surroundings ; some, for 
example, to live under water, others on 'land. Moreover, each 
individual of a species has inherited the power of calling into play 
innumerable and often extremely dexterous ways of adjusting or 
adapting itself to harmful situations. When these adaptations 
are very perfect so that the organism is able to meet the situation 
with little or no disturbance of its functions we may consider 
the resulting adjustment as a normal condition. When, on the 
other hand, the adaptation is more or less imperfect, an abnormal 
or diseased condition will be brought about. For example, when 
any tissue of the human body has been subjected to a direct 
mechanical injury, e.g., a wound, there results an adjustment of 
the cell activities which we call the healing process. This adjust- 
ment while not ideally perfect is in a very high degree efficient, 
and when not interfered with in any way proceeds to repair the 
defect with such smoothness, certainty, and speed and with so 
little disturbance of the organism as a whole that we are nearly 
or quite justified in calling it a normal process, although the cell 
activities involved are quite different from those exercised in 
ordinary times. Surgery is wholly dependent upon this nearly 



CELLS OF BODY AND INVADING CELLS 17 

perfect adaptation, for without it surgery would be impossible, 
and the fundamental problems of practical surgery are concerned 
with the selection of methods for attaining the end desired which 
shall place the smallest possible obstacles in the path of the heal- 
ing process. On the other hand, from what has already been 
said at the beginning of this chapter it is quite evident that 
when a wound is infected the healing process is very seriously 
interfered with. A new situation is developed to meet which 
the organism is very imperfectly adapted, and the condition 
which results cannot be called normal, but must be regarded as 
one of disease. There is thus no hard and fast line between the 
normal and the abnormal, i.e., between health and disease. 
Disease may be said to be present when as the result of an imper- 
fect adaptation to an injurious influence the normal balance of 
the activities of the body -cells is destroyed. 

V. INFECTION 

Now one of the most potent and also one of the most common 
causes of disease — that is to say, of such a disturbance of the 
disciplined harmony in the activities of the cells of the organism 
— consists in the entrance, among the cells of the body, of other 
cells which invade it from the outer world. When such alien 
and hostile cells, not subject to the discipline of its controlling 
system, obtain entrance into the body and find in any of its 
tissues a situation and surroundings suitable for their growth, 
they multiply there, and by their growth and the secretions 
which they produce they cause either a destruction of the body- 
cells or an interference with their normal working. This invasion 
of alien cells harmful to the body we speak of as an " infection," 
and the effects in the body of their harmful activities we call an 
infectious disease. 

All of the large and familiar class of infectious diseases are 
caused by the entrance among the body-cells of unicellular 
organisms from without. It must not be supposed, however, 
that all the unicellular organisms can thus invade the body. On 
the contrary, the vast majority of these organisms, which exist 
in such countless numbers all about us, find in the tissues of 
the animal body conditions altogether unfavorable for them, 
and they can no more live there than a fish can live out of water 
or an air-breathing animal can live under the sea. Unfortunately 
for us, however, there are certain species of microorganisms 
2 



lg INFECTION 

which are specially adapted to live and multiply within the 
tissues of our bodies. Fortunately for us, on the other hand, 
these species are relatively few. 

There are certain species of the hostile invaders which grow 
readily in any tissue of the body where an injury has taken 
place. An open wound offers an ideal portal of entrance for them 
and the injured tissues a favorable soil for their growth. 

Infection through a wound with these particular species of 
alien cells we speak of as "septic" infection, and the resulting 
disease affecting the wound and the body as a whole is known 
as "sepsis," "septicaemia," or "septicopyemia." 

VI. THE SINGLE-CELLED ORGANISMS CONCERNED IN 
INFECTION 

1. Bacteria. — Among the microorganisms which play the 
part of hostile invaders among the body-cells, the bacteria are 
the most numerous and important class. All the organisms con- 
cerned in wound infections belong to the bacteria. The bacterial 
cell is characterized by extremely minute size, great simplicity 
in form, and apparent simplicity in structure and manner of 
reproduction. On the other hand, the greatest variety and com- 
plexity is shown in the character of the cell activities, i.e., in 
the chemical composition of the secretions which the cells pro- 
duce and in the different conditions under which they thrive. 
An immense number of distinct species can be recognized mainly 
by these differences in vital activities, the form differences being 
relatively insignificant or even in some cases indistinguishable. 
The cell is many times smaller than the average size of the cells 
which make up the structure of animals and plants (Fig. 3). 
Bacteria are either rod-shaped or spherical in form. Straight 
rods are called bacilli (Fig. 4), rods with a slight curve are known 
as spirilla (Fig. 5). The rods vary considerably m length and 
thickness and may have rounded or blunt ends. Bacilli are either 
motile or non-motile, the former possessing whip-lash-like append- 
ages, attached sometimes to the ends, sometimes to all sides, 
which by their rapid vibration propel the organism through the 
surrounding fluid (Fig. 6). The spherical forms, known as micro- 
cocci, differ only slightly in size, but characteristic differences 
in group mg appear, those which are seen in pairs being known 
as diplococci (Fig. 7), others which appear in chains, like a string 
of beads, are called streptococci (Fig. 8), while staphylococci 



CELLS OF BODY AND INVADING CELLS 19 

(Fig. 9) show an arrangement in irregular bunches. Reproduc- 
tion takes place by simple division. A fissure appears in the 
centre of the bacillus or the micrococcus, which presently sepa- 
rates it into two equal parts. Each half grows to a full-sized 
organism and then again divides. This process can be observed, 




Fig. 3. — Each side of the square represents one-thousandth of an inch. The relative 
size is then shown of (1) a red blood-corpuscle, (2) the anthrax bacillus, (3) the typhoid 
bacillus, (4) the tubercle bacillus, (5) the influenza bacillus, (6) the diphtheria bacillus, 
(7) the tetanus bacillus, (8) a micrococcus. 

and has been shown to take place under favorable conditions in 
about twenty minutes. The result is a rapidity of multiplication 
that is difficult to comprehend. A simple calculation will show 
that if this rate of increase continued uninterrupted for a period 
of twelve hours we should then have arising from a single organism 
a number equal to more than ten times the entire human popula- 



20 INFECTION 

tion of the globe. Under natural conditions, of course, many 
influences check this process, but multiplication is nevertheless 
enormously rapid. Some species of bacilli produce spores, a 
method of reproduction somewhat analogous to seed formation 
in higher plants. The spore appears in the middle or end of the 
bacillus as a bright glistening body, the bacterial cell later melting 
away and leaving the spore free (Fig. 10). Each cell, except in 
rare instances, produces only a single spore, so that multiplica- 
tion does not result from this process. The office of the spore 
appears to be to preserve the species from destruction under 
unfavorable conditions. In this " resting stage" the organism is 
highly resistant to heat and chemical disinfectants and may remain 
alive for years in the dried condition. When again placed under 






— * 




¥ 


r 


* J M V 


A 






V 


* * 
1 




* 


vy - f V 


'iG 


. 1 


i. — Spirilli of Asiatic 
cholera (Carr). 



Fig. 4. — Diphtheria bacilli. (Microphoto- 
graph by Carr.) 

favorable conditions of moisture, temperature, food supply, etc., 
the spore germinates into a bacillus and the process of reproduction 
by fission recommences. Bacteria absorb nourishment through the 
external surface of the cell from the surrounding materials, these 
being acted on as a preparation for absorption by ferments secreted 
by the cell. Bacteria thus digest their food outside the cell body, a 
process which results in chemical changes in the matter surround- 
ing them; changes made evident in the various processes of fer- 
mentation, putrefaction and decomposition of organic substances 
resulting from the action of " saphrophytic " bacteria, and in the 
case of the disease-producing or " pathogenic" species, in injury 
or destruction of the tissue cells of higher organisms invaded by 
them. Abundant moisture is essential for bacterial growth. The 



CELLS OF BODY AND INVADING CELLS 



21 







f 

/ y ' 






__ 



Fig. 6. — Bacillus subtilis showing flagellse Fig. 7. — Diplococcus pneumoniae. (Micro- 



( Gray) 



photograph by Carr.) 




-A 



Fig. 8. — Streptococci. (Microphotograph 
by Gray.) 




Fig. 9. — Staphylococci. (Micro- 
photograph by Carr.) 



- / 



Fig. 10. — Bacilli showing spores. 



22 INFECTION 

presence of air or free oxygen is essential for the growth of some 
and absolutely inhibits the growth of others. The former are 
called "aerobic," the latter "anaerobic"; others which grow 
equally well in both conditions are known as tl facultative" 
species. As they are seen massed in " colonies" on the surface 
of culture media in the laboratory, most bacteria are grayish 
white in color, but many species produce pigments and the col- 
onies of these may show brilliant coloring, orange yellow or red 
being most common, but blue-green and violet coloring may 
also occur. The limits of temperature within which bacteria 
grow are rather wide. For each species there is an upper and a 
lower limit above or below which growth will not take place; 
between these is an optimum temperature most favorable for 
growth; above the maximum temperature for growth is the ther- 
mal death point at which the organism is killed. All vegetative 
(not spore-bearing) forms are destroyed by a temperature con- 
siderably below the boiling point of water. Spores withstand a 
temperature much higher than this for a considerable time. 
Freezing does not kill bacteria with certainty, and some may 
withstand even the extreme low temperature of liquid air. Most 
vegetative forms are readily killed by drying, but some may 
survive for days or even weeks. Bacteria are destroyed by chemi- 
cal agents such as carbolic acid, iodine, bichloride of mercury 
and a host of others, but in every known instance those 
chemical substances which kill bacteria are equally or even more 
destructive to the cells of the human body, so that we can- 
not combat bacterial infection by means of drugs administered 
in the hope of destroying the invading cells without poisoning 
the patient. The readiness with which bacteria are cultivated 
in the laboratory, upon simple and easily prepared media, by 
the methods introduced by Koch, has resulted in a great accu- 
mulation of knowledge concerning them which has been applied 
in many ways in the prevention, diagnosis and treatment 
of disease. 

2. The Protozoa. — These are unicellular organisms which are 
classed as belonging to the animal kingdom, while the bacteria 
are regarded as vegetable in nature. The species of protozoa 
are very numerous and they are very widely distributed, being 
present everywhere in sea-water, in all stagnant fresh water, 
and in all moist soils. Active living forms are never present in 
the air, but many are able to pass into a resting stage in the form 



CELLS OF BODY AND INVADING CELLS 23 

of spores or cysts, in which condition they may survive for some 
time in the dried state and be carried through the air. They are 
often parasitic in habit, and, while comparatively few species 
are the cause of disease in man, many others cause disease in 
domestic animals and plants which are useful to man. The 
protozoa are far more complex and varied in form than the bac- 
teria, and many of the single cells show remarkable complex 
appendages and other variations of structure comparable to the 
specialized organs of the higher forms of life. Their modes of 
multiplication are also more complicated and varied than in the 
case of the bacteria. Bacteria, like plants, absorb their nourish- 
ment from substances in solution in the fluid surrounding them. 
The protozoa, like animals, derive their food from other organ- 
isms, chiefly bacteria. They do not multiply so rapidly as the 
bacteria. Except in a very few instances it has not been found 
possible to cultivate them in the laboratory. 

3. Yeasts and Moulds. — Infections with single-celled organ- 
isms of this class do occur, but they are few and rare and need 
not be considered here. 

4. The Filterable Viruses. — 'There is still another class of 
infections our knowledge of which stands in a very curious 
position. These diseases can be transmitted to a healthy animal 
by injecting into its tissues a very small quantity of the blood 
or of certain secretions from a diseased animal, and this can be 
done even after the blood or secretion has been passed through 
a porcelain filter, the pores of which are fine enough to stop the 
smallest known bacteria. These germs, whatever they are, must 
be from five to ten times smaller than the smallest of the 
bacteria. At least three human diseases belong to this class: 
yellow fever, the disease known as infantile paralysis or polio- 
myelitis, which especially affects children, and a tropical disease 
known as dengue or break-bone fever. Altogether some twenty 
diseases of this nature, affecting plants and animals, are known. 
No filterable organisms not related to disease have ever been 
demonstrated. 

5. Unknown Invaders. — In spite of all the study that has 
been devoted to the infectious diseases, there are still a number 
in which the infectious agent — the invading cell — has not been 
found. Among these are such prevalent diseases as measles and 
scarlet fever. We know that they are infectious; we know, there- 
fore, that they must be due to a living agent, an invading cell, 



24 INFECTION 

but as to what the invaders may be like,, we are up to the present 
time utterly in the dark. 

Finally, there are a few diseases about which our knowledge 
is even less. They may possibly be infectious in origin,, but we 
cannot prove either that this is true or that it is not true. In 
argument we may make a plausible case on either side, but there 
is no convincing evidence to decide the question. The malignant 
tumors perhaps are the most notable diseases in regard to which 
we are in this unfortunate position. 



CHAPTER II 

SOURCES AND MODES OF INFECTION 
I. NUMBER OF SPECIES CONCERNED 

We have defined infection as a disturbance of the normal 
activities of the cells of the body, due to an invasion of its tissues 
by alien cells from without. We have seen that the world about 
us is teeming with invisible life, consisting of countless species 
and varieties of single-celled organisms, infinitely small and insig- 
nificant individually, but irresistibly potent because of their 
prodigious numbers, and the almost inconceivable rapidity with 
which they multiply. In the great majority of instances the 
work they do is to dissolve and melt away dead organic matter 
wherever it may be found; a beneficent work, for the most part, 
in its relation to the welfare of mankind, since without it there 
would be no decay, the soil would soon become exhausted of its 
fertility, and the surface of the earth choked with its own dead. 

A certain number of species, however, are parasitic in their 
habits; that is, their natural dwelling place is within, or on, the 
living bodies of some of the higher many-celled organisms. Some 
of these parasites do no harm to their hosts, but others cause 
serious and often fatal injury to the tissue cells of the higher 
organisms upon which they live, giving rise to many diseases in 
plants, in the lower animals, and in man. Only a very few 
species among the myriads are able to become hostile invaders 
in the human body, scarcely more than two score altogether, 
although, if we include all the occasional invaders and some which 
are quite incapable of doing serious harm, this number will be 
somewhat increased. On the other hand, if we include only those 
that are of special importance, because of their wide distribution 
and the high mortality for which they are responsible, we shall 
have a list that can almost be counted on the fingers. Our 
business here concerns only those which are of importance in 
relation to wound infection, including some half-dozen species 
of bacteria; but before we can begin the study of these under- 
standingly we need to have clearly in mind certain facts about 
the sources and modes of infection. 

25 



26 INFECTION 



II. DISTRIBUTION OF BACTERIA 

1. In the Air. — If we expose to the air for ten minutes a 
thin layer of culture jelly contained in one of the small glass 
plates or " Petri dishes/' and then replace the cover and put 
the plate in the incubator over night, we shall find next morning 
upon the surface of the medium a number of little round colonies 
of bacteria an eighth to a quarter of an inch in diameter, looking 
like little drops of paint. Each colony will have grown from a 
single germ that has fallen upon the surface of the plate while 
it was uncovered. There msiy be only five or six, or there may 
be twenty or thirty or more of the colonies, representing a variety 
of different species. There will certainly be some of a yellow 
color, some gray, and possibly some of a bright red. There will 
very likely be some of the fluffy growth that we recognize as 
mould. The number of colonies will vary; in a quiet room there 
will be few, in a dusty one many. Bacteria are sticky things 
and apt to adhere to particles of dust. There will be more in 
the city streets than in the country; more in the lowlands than 
in the mountains; comparatively few or none at sea, in desert 
regions, and particularly in polar regions. Among them micro- 
cocci and moulds will predominate. It will be rather unusual to 
find any of the pathogenic species upon our plate. Most of them 
come from the great reservoirs of saprophytic bacteria that are 
found in decomposing vegetation. 

2. In Water. — In water we should find bacteria, for the most 
part, far more numerous than in the air. Here we must use a 
smaller measure for our standard. It is usual to estimate the 
number in a cubic centimetre, a quantity about equal to sixteen 
drops. In a mountain spring trickling from the rocks and in 
deep wells we may find the water almost sterile, that is, containing 
few bacteria or none. They have been filtered out in their pas- 
sage through the deeper layers of the soil. In an ordinary stream 
the water will probably be found to contain from two or three 
hundred to five thousand or more bacteria per cubic centimetre. 
In a polluted stream the number may rise to enormous totals, a 
million up to fifty million or even more per cubic centimetre. 
Both bacilli and micrococci will be found here in abundance. 
But, except in specimens taken from sewage-polluted streams, 
disease-producing germs are not numerous. 

A rapidly flowing stream tends quickly to purify itself, and 



SOURCES AND MODES OF INFECTION 27 

a few miles below a point of contamination the number of bacteria 
contained will be found to be greatly diminished. 

3. The Soil. — The superficial layers of the soil contain bacteria 
in great abundance. It is more difficult to determine the number 
in the soil than in water or air, and any estimate given as to an 
average would be useless and misleading. The variations are, 
of course, very great. In a moist soil contaminated by animal 
excreta or decaying vegetation the number is enormous. In a 
dry soil not subject to such contamination the number is relatively 
small. At about three feet below the surface the earth becomes 
practically sterile, no bacteria being ordinarily found below this 
level except in loose gravel, where they may be present at a 
somewhat greater depth. All the varieties of bacteria are in- 
cluded among those found in the soil, but it may be noted that 
the spore-bearing bacilli are relatively numerous here. Here, 
too, is the chief abode of moulds and other fungi, including 
yeasts, and very many species of single-celled animals are also 
present in great numbers. As regards the presence of pathogenic 
bacteria in the soil, perhaps the one species most to be dreaded 
is the deadly tetanus bacillus, which, as has been said, is found 
occasionally in garden earth and more commonly in stable-yards. 
It is a possible danger in the soil almost anywhere in thickly 
inhabited regions, and the same may be said of some other species 
of bacteria that are concerned in the production of disease, 
particularly those that thrive in the intestinal canals of men and 
domestic animals. Nevertheless, apart from areas liable to be 
contaminated with human or animal excreta, the bacteria of the 
soil are rarely pathogenic to man. 

4. Food. — The presence of bacteria in various articles of food 
is constantly manifested by the evidence of decomposition. We 
may take milk as a typical example. What may be called the 
normal bacterial content of milk is surprisingly large. Milk 
containing no more than ten thousand bacteria to the cubic 
centimetre is considered the standard of attainable purity. The 
production in marketable quantities of milk in which the bacteria 
do not exceed this number is rarely attained. A milk that does 
not contain over one hundred thousand bacteria to the cubic 
centimetre is regarded as just passably clean by most of our 
health boards. A milk containing more than this is considered 
a dirty milk, and yet in all probability the majority of the milk 
now marketed contains, at the time it reaches the table of the 



28 INFECTION 

consumer, vastly greater numbers of bacteria than this, often 
going up into the millions per cubic centimetre. It is true that 
the majority of these bacteria are not pathogenic, often not even 
unwholesome; nevertheless, dangerous and deadly disease germs 
are so often present in milk that the methods of its production 
and distribution are among the most important of the problems 
concerned with the prevention of infectious disease. Notable 
among the diseases that are not infrequently conveyed by milk 
are typhoid fever, streptococcus infections of the throat, dysentery 
and diarrhoeal diseases and tuberculosis. 

Bacteria, as has been said, readily adhere to any surface they 
come in contact with, and all the innumerable articles of use and 
ornament that surround us are more or less covered with them. 

5. The Human Body. — The skin has its bacterial flora, dis- 
tributed not only on the surface but in the ducts and crypts of 
its glandular organs. Here there are always micrococci capable 
of giving rise to the infection of wounds, and many other infectious 
germs may at times be found upon the skin, particularly of those 
who come in contact with disease. Bacteria are always present 
and even multiply abundantly in the mouth and throat. Here, 
also, certain species capable of invading the body may be prac- 
tically always found in the healthy individual, and others are 
occasionally present. Many bacteria swallowed from the mouth 
and taken in with the food are destroyed in the stomach by the 
acid gastric juice, and that portion of the small intestine into 
which the food passes after leaving the stomach contains fewer 
bacteria than any other part of the intestinal canal. Lower 
down in the intestine, however, the bacteria multiply enormously 
until they actually form a considerable part of the bulk of the 
contents of the large intestine. From one-eighth to one-quarter 
by weight of the dried faeces consist of bacterial cells. The species 
present in the intestines are fairly constant and among those 
normalh r present are a number that are capable of invading the 
body tissues under certain conditions. 

III. THE RELATION OF PARASITE TO HOST 

When we think of the various ways in which infection may 
come to us it is natural to assume that the germs of disease always 
pass directly from the sick to the well and that the means of 
transmission is mainly through the agency of the air. This has 
probably been the generally accepted idea from the beginning 



SOURCES AND MODES OF INFECTION 29 

of our knowledge of these diseases and still influences largely 
our practice in regard to preventive measures. But increasing 
knowledge is making it more and more evident that the problem 
of the sources of infection is far from being so simple a matter. 
An individual sick with an infectious disease is not by any means 
the only, and in many cases not the chief, source of infection to 
others, and transmission through the air is, with a few excep- 
tions, an almost negligible factor. To understand this we must 
take into account certain facts about the relation of parasite to 
host. We have said that the presence of a parasitic organism is 
not necessarily harmful to the host, and we have also pointed out 
that certain individuals of a species may be apparently entirely 
insusceptible to an infectious disease to which other individuals 
of the same species readily succumb. That an invading organism 
will grow in the body of one individual and not in that of another 
is hard enough to explain, but we must also recognize the fact 
that the same organism may grow in the bodies of two individuals, 
producing symptoms of disease of the gravest character in one 
and no symptoms whatever in the other. It happens often that 
after an attack of disease the organisms which were the cause of 
the trouble may remain alive and continue to multiply in the 
body long after the patient has fully recovered; but it is also 
true that the germs of an infectious disease may be present in 
the body of an individual who has never had an attack of the 
disease. In the history of many of the infections there are found 
cases where the symptoms are so mild that they are scarcely 
recognizable, and it is but a step farther to find that there are 
cases of infection with no symptoms at all. How greatly these 
facts complicate the problem of determining and controlling the 
sources of infection will be readily seen, but even this is not the 
whole story. 

When an organism acquires the parasitic habit, there is 
always a tendency for the parasite and host to become gradually 
adapted or, so to speak, used to each other, so that the mutual 
effects of a harmful nature are reduced to a minimum. It is 
obvious that, when the presence of the invader is rapidly fatal 
to the host, this fact works as much to its own disadvantage as 
to that of the species of animal invaded. The invaders die with 
their victim, and their chance of transmission to a new individual 
is diminished in proportion to the rapidity with which they kill. 
It is a curious fact that the most deadly among the infections 



30 INFECTION" 

are also the most rare: thus tetanus, anthrax and rabies are 
infections that almost invariably kill. In the case of the first 
two of these named, the organisms concerned have the immense 
advantage that they are spore producers and thus are able to sur- 
vive indefinitely under the most unfavorable conditions. Yet the 
number of their victims is small in proportion to their deadliness. 

Heredity plays an important part in gradually bringing about 
a mutual adaptation between parasite and host. The individuals 
having greater resistance to the invaders are the ones that 
survive, to transmit this quality to then descendants: on the 
other hand, the less deadly of the invading organisms are favored 
in then chances of survival. 

Let us suppose now that a certain unicellular organism has 
acquired the parasitic habit, living in the body of a certain host, 
and that the two have become adapted to each other so that the 
host suffers little or no injury from the presence of the parasite. 
The host in this case we will suppose is one of the wild animals 
of the region, or perhaps one of the domestic animals. We will 
call this the habitual host. Suppose now that the same organism 
is also able to invade the tissues of some other animal, for example 
the human body, and in this new host its presence gives rise to 
grave disturbances. We shall have then an infectious disease 
of such a character that the main source of infection is not from 
the victims of the disease but comes rather from the inexhaustible 
reservoir found in the bodies of habitual hosts, who are unaffected 
by the presence of the organism. This is exactly the condition 
of affairs with regard to a number of infectious diseases of man 
and of the domestic animals, and it is quite possible that there 
are others of which the same is true, although the habitual host 
has not yet been discovered. The organism which is the cause 
of sleeping sickness, a disease invariably fatal to human beings, 
which prevails in certain regions of Africa, is transmitted by a 
biting fly from certain wild animals of the region who are its 
habitual hosts. The domestic goat is the habitual host of the 
micrococcus which is the cause oi Malta fever, the infection 
being conveyed through the milk. There is evidence that septic 
streptococci may sometimes be present in the milk from appar- 
ently healthy cows, and it seems highly probable, though per- 
haps not proved, that milk from animals which show no outward 
sign of disease is one of the sources of infection with the tubercle 
bacillu-. 



SOURCES AND MODES OF INFECTION 31 



IV. CARRIERS OF DISEASE ORGANISMS 

When a healthy animal or human being is the bearer of an 
organism which is capable of becoming a disease-producing 
invader in the tissues of an animal of another species, or of another 
individual of its own species, we speak of it as a disease " carrier." 
Diseased individuals are of course also carriers of disease, but 
we use the word with reference particularly to healthy carriers. 
Among human beings we have chronic carriers, or those who, 
having had an attack of disease, retain the invading cells actively 
growing in their bodies for an indefinite time after they have 
been restored to perfect health. We have also healthy carriers, 
or those who have never had an attack of a certain infection 
and yet carry in their bodies the organism of that disease. Wild 
or domestic animals, and also insects, which are the habitual 
hosts of an infectious germ, are also spoken of as carriers. A 
certain number of those who have recovered from typhoid 
fever carry in the intestinal canal living and active typhoid 
bacilli for months or years, or even for the remainder of their 
lives. It is impossible to know how many of these there are, 
but there is evidence that they may amount to two or three per 
cent, of the population. Diphtheria bacilli are often present in 
the throat for weeks or months after recovery from the disease, 
and wherever there is an epidemic they are also to be found in 
the throats of a varying number of healthy individuals, some- 
times in as many as ten or fifteen per cent, of those examined. 
With regard to the pneumococcus, which is the usual cause of 
pneumonia, and of a number of other diseased conditions in the 
human body, the case is a peculiar one. This organism is harm- 
lessly present in the mouths of a large percentage of human 
beings, but is able to induce an attack of disease only under 
certain conditions which favor its invasion, probably because they 
lower the resisting power of the body. Thus prolonged exposure 
to cold and wet, particularly with exhausting labor, favors the 
development of pneumonia, as does also the presence of certain 
other infections, the administration of an anaesthetic, and so on. 

The discovery of the typhoid carrier was felt to be almost 
revolutionary in its bearing upon our conception of the sources 
of infectious disease, and our sanitary authorities have been 
sorely puzzled as to the proper method of dealing with the prob- 
lem. The difficulties of detecting these carriers, and also of 



32 INFECTION 

dealing effectively with them after detection, are almost insuper- 
able. Obviously a typhoid carrier whose occupation is concerned 
in any way with the preparation of food is a constant source of 
danger to others. Some few individual instances of this kind 
have been investigated, showing evidence that a large number 
of persons have been infected by a single carrier. There is some- 
thing appalling in the thought of such an unfortunate individual 
going through life unconsciously leaving behind him a constantly 
lengthening trail of disease and death. And yet after all there 
was nothing really new or revolutionary in this discovery. The 
facts about pneumonia, which we have stated, had long been 
recognized, and for many years it had been known that, without 
exception, every surgeon, nurse, or other person who assists in 
surgical operative work, is a healthy carrier of the organisms 
concerned in wound infection. 

V. MODES OF TRANSMISSION 

The dissemination of infectious germs from the sick, the 
carriers, or the animal hosts depends on the method by which 
they are thrown out from the body. In some diseases, as for 
example in malaria, yellow fever, and sleeping sickness, the 
organisms cannot find exit from the body alive unless they are 
withdrawn directly with the blood. It is possible to transmit 
such diseases by means of a hypodermic syringe, but the ordinary 
method is by the bite of a mosquito or other insect. The principal 
avenues by which infecting cells leave the body are through 
the expectorated secretions from the mouth and throat, the 
discharges from the nasal passages, and with the urine and faeces. 
Other avenues of exit are the secretion of milk, discharges from 
abscesses and ulcerations, and even the secretion of the sweat- 
glands. As a rule, probably ninety per cent, of the organisms 
so eliminated are dead at the time they leave the body, but the 
remaining fraction may represent prodigious numbers. The 
various possible modes of transmission are through the air, 
through the contamination of drinking water and food, through 
direct contact, and through contact with contaminated articles, 
such for example as the public drinking cup and all the innumer- 
able things that may be soiled with infection-bearing secretions. 
Flies and other insects may transmit bacteria mechanically to 
articles of food or to an open wound, and finally the importance 
as bearers of infection of the busy human fingers, which are con- 



SOURCES AND MODES OF INFECTION 33 

stantly touching everything within their reach, can hardly be 
overestimated. 

There are two ways in which the germs of disease may be 
disseminated through the air. One is through the drying of 
infected secretions and excretions from the body, which are then 
carried about by air currents in the form of dust. Most of the 
organisms of disease do not live very long when dried, particularly 
if exposed at the same time to sunlight, yet some of them can 
survive under these conditions for several days at least, and 
certain diseases may undoubtedly be transmitted through 
inhaled particles of infected dust. The importance of this method 
of dissemination has quite certainly been greatly overestimated 
in the past, and it is probably not the usual mode of transmission 
in the case of any infectious disease and for the majority is a 
practically negligible factor. The other mode by which infectious 
organisms are carried through the air is of far more importance. 
It is the so-called droplet or mouth-spray method. In talking, 
coughing, or sneezing, and even in breathing through the open 
mouth, there is always driven out into the air a fine, often in- 
visible, spray consisting of minute droplets of mucus, and in 
these droplets there are invariably present some of the bacteria 
of whatever kind that happen to be present in the mouth. The 
spray can be shown experimentally to extend for a considerable 
distance up to several yards, though ordinarily five or six feet 
is the limit of its reach. Any infection where the organism is 
present in the mouth, nose, or throat may be thus conveyed, 
the spray being directly inhaled or more often perhaps falling 
on the clothing or skin surfaces, particularly the hands, of persons 
standing near, to be later conveyed to the mouth. Diphtheria 
and influenza, for example, are doubtless often conveyed in this 
way. Both of these methods of conveyance through the air are 
of course more liable to occur in a closed space, like a room or 
street-car, than in the open. 



CHAPTER III 

INFECTION IN WOUNDS 

I. DEFINITIONS 

When any of the tissues of the body are divided or separated 
by violence, as for example by a cutting or tearing or crushing 
injury, we have what is known as a wound. A wound may vary 
in extent from the slightest scratch up to any degree of severity. 
Accidental wounds are described under various terms which 
indicate their character, such as incised, lacerated, contused, 
and punctured wounds. A penetrating wound is one that enters 
any of the body cavities, such as the head, chest, or abdomen. 
A snake' bite is an example of what is meant by a poisoned 
wound. A subcutaneous wound is one in which the deeper tissues 
have been torn without division of the skin. When the skin is 
involved we speak of an open wound. An infected wound is one 
into which living single-celled pathogenic (disease-producing) 
organisms have found entrance. A septic wound is one which 
is infected with certain species of bacteria to be presently de- 
scribed. A suppurating wound is one from which pus is being 
discharged, a condition always the result of septic infection. The 
word sepsis means the diseased condition of the body due to the 
invasion through a wound or otherwise of the particular species 
of bacteria concerned in septic infection. By an aseptic or clean 
wound we mean one which is entirely free from all microorganisms 
capable of giving rise to local or general injury within the body. 
The healing of a wound is the process of repair, due to the activi- 
ties of the body-cells of the wounded part, whereby the divided 
tissues are reunited and restored more or less perfectly to their 
natural condition. Normal or primary healing is that which 
takes place in an aseptic wound. 

II. OPERATIVE WOUNDS 

The wounds which particularly claim our attention are those 

which have been deliberately made by the surgeon, with some 

definite purpose of a remedial character in view. Such wounds 

are called surgical or operative wounds. Any remedial measure 

34 



INFECTION IN WOUNDS 35 

carried out by the surgeon with his hands or with instruments 
is called an operation. A bloodless operation is one in which no 
open wound is made, as for example the "setting" of a fracture 
or the "reduction" of a dislocated joint. Any operation which 
requires the making of an incision through the skin or mucous 
membrane is known as an open operation. The object of an 
open operation may be either to remove something contained 
within the body, the continued presence of which is a menace 
to health and life, such as a foreign body, a diseased or injured 
organ or portion of tissue, or an abnormal accumulation of the 
products of disease; or else to correct some physical or mechanical 
defect. The special characteristics of these operative wounds 
should be clearly understood by the nurse in order that her work 
in the operating room and in the care of surgical cases after 
operation may be intelligently performed. 

As a general rule every open surgical operation consists of 
three main steps or stages : (1) exposure of the part to be operated 
on is secured by cutting or separating the overlying tissues, so as 
to bring the diseased or injured area clearly into view and make 
it easily accessible; (2) the remedial measures required in the 
particular case are then carried out, a great variety of procedures 
being included under this head; (3) closure of the wound is accom- 
plished by the use of stitches or "sutures," so as to restore the 
parts as nearly as possible to their normal relations. 

The first step begins with the incision through the skin or 
mucous membrane. This varies in position, direction, and 
extent with the requirements of the case. It may be a single 
straight or curved incision, or there may be several incisions 
joining at different angles, so as to outline flaps of skin, which 
are separated from the underlying tissue and temporarily turned 
aside out of the way. The dissection proceeds with the division 
by knife or scissors of the superficial fascia or tissue lying immedi- 
ately under the skin, with its layer of fat of varying thickness, 
then of the deep fascia covering the muscles, and finally with the 
separation and pulling aside of the muscles and other structures 
overlying the part to be operated upon. Large nerves are never 
divided in this procedure and large arteries or veins only when 
absolutely necessary. Many small blood-vessels are necessarily 
cut, and bleeding from these is at once checked by pinching 
with instruments known as clamps or haemostatic (blood-checking) 
forceps, which temporarily compress the ends of the divided 



36 INFECTION 

vessels. Permanent arrest of hemorrhage is later secured by 
tying the bleeding points with threads of silk, linen, or other 
material specially prepared for the purpose. These ties are known 
as ligatures and they remain permanently in the wound. Bleeding 
from the cut capillaries, too fine to be tied, is checked by pressure 
with pads of gauze called sponges, and these are also used to 
soak up the blood which at times obscures the field. Many 
operations require the opening of one of the large cavities of 
the body, as for example the abdomen, to secure access to the 
stomach, the intestines, the uterus and ovaries, and other abdomi- 
nal organs. The other large cavities to which a way of entrance 
must be found are the head and the chest or thorax, and here, 
on account of the bony walls which enclose them, special means 
must be employed involving the cutting away of portions of ribs 
or of the skull, or else the formation of flaps containing bone as 
well as soft parts, which can be temporarily turned aside, exposing 
the underlying organs, and later replaced in their original position. 
The second stage consists in carrying out the remedial meas- 
ures to accomplish which the operation was undertaken, and may 
be called the operation proper. It includes, of course, a very 
great variety of procedures intended for the relief of the large 
number of injuries, abnormalities, and diseases that are amenable 
to surgical treatment. They are too numerous and varied to 
be briefly summarized here. One feature of operative work 
remains to be mentioned, namely } the use of drainage. All 
surgical operations fall into one of two classes : clean cases, where 
no alien invading cells are present, and infected cases. The 
latter include those where the operation is undertaken for the 
relief of conditions resulting from septic infection in some part 
of the body. In these, one of the principal objects to be attained 
is to provide for the escape of poisonous accumulations caused 
by the invading organisms. For this purpose rubber tubes or 
wicks of gauze are inserted through the wound, extending from 
the skin surface down to the infected area, so as to keep open a 
way for the escape of the toxic products of the infection. These 
drains, as they are called, remain in place for a variable time, 
sometimes for weeks. The deadly secretions of the alien cells 
are by this means continually discharged from the body instead 
of being retained and absorbed, thus giving the body-cells a 
great advantage in their struggle with the invaders. In very 
deep and extensive clean wounds temporary drains are sometimes 



INFECTION IN WOUNDS 37 

inserted to prevent the retention of blood and serum in the wound. 
They are removed at the end of from twenty-four to forty-eight 
hours. 

The third stage in a surgical operation consists in closing the 
wound by bringing the divided tissues together, restoring them 
to their normal positions and relation to each other, and fixing 
them when necessary by means of stitches, or " sutures," of silk 
or other material. The cut edges of the incisions in the skin are 
united with particular exactness and care. Finally the wound 
is covered by a protective " dressing." This usually consists of 
loosely woven absorbent gauze laid over the wound and held in 
place by straps of adhesive plaster, bandages, or a " binder." 

Throughout all the steps of an open operation, from the 
first preparation to the placing of the dressing, the dominating 
idea in the minds of every one engaged in the work, never to be 
forgotten for an instant, must be to prevent the entrance into 
the wound of the bacteria of septic infection. The means that 
are used to attain this end have been purposely omitted here, 
since they form the principal theme of many subsequent chapters. 
In this place we are concerned rather with answering the questions 
as to what happens to such a wound when no infecting organisms 
have been allowed to enter it, and, on the other hand, what is 
the result when infection has occurred. 

III. NORMAL HEALING 

In every fresh wound there will occur a certain amount of 
oozing from the divided capillaries and lymphatic vessels, first 
of bright red blood, later of a clear fluid only slightly blood 
stained. In very extensive operative wounds this oozing will 
be of considerable amount and may last for several hours. Later, 
at the first dressing, the gauze covering the wound will be found 
deeply stained with this discharge. Pain in the wound may be 
present immediately after the operation, but it is rarely severe 
and ceases within a few hours. Pain is more often due to too 
tight bandaging or to pressure of skin stitches than to the wound 
itself. Pain resulting from movements of the body which call 
into play the muscles in the region of the wound will be present 
for several days. As a rule there is no elevation of the temperature 
of the body resulting from an operative wound in clean cases 
(Fig. 11), but in extensive wounds there may be a rise of from one 
to four degrees, beginning within twenty-four hours and lasting 



3S 



INFECTION 




Fig. 11. — Chart showing normal 
temperature after operation (salpin- 
gectomy). 



until the third or fourth day (Fig. 
12). This is the so-called traumatic 
fever, resulting either from the 
absorption of the dead tissue cells 
or of blood that has collected in 
the wound, or else from increased 
oxidation due to the psychic and 
traumatic stimuli of the operation. 
This slight fever, occurring within 
the first three days, is quite harm- 
Less and calls for no interference 
with the wound. On the other hand, 
a sudden rise of temperature appear- 
ing from the third to the fifth day 
almost always means infection (Fig. 
13), and if it persists for more than 
twenty-four hours calls for a change 
of the dressings and an examination 
of the wound. As a rule, the dress- 
ing of a clean wound is allowed to 
remain undisturbed for from five to 
ten days, the longer the better, for 
there is always some risk of infecting 
a wound at the first dressing if it 
is done too early. When such a 
clean wound is dressed and the skin 
stitches removed at any time from 
the fourth day onward, the edges of 
the skin incision will be found to be 
quite firmly united, there will be no 
discharge from the wound, the dress- 
ings being free from moisture al- 
though deeply stained with dried 
blood. The skin about the incision 
will be normal in appearance. There 
will be no redness or swelling and 
scarcely any soreness on pressure. 
Even very extensive wounds will 
thus appear to be quite perfectly 
healed by the fourth or fifth day 



DATE. Zo 




£L2j£ZjLMl*1-23-*!$-2°-.J-Z 



Fig. 12. — Chart showing temperature rise due to trauma and not to infection. 
Amputation for crush of foot. (Chart by Miss Kathleen Carroll.) 

39 



40 



INFECTION 




Fig. 13. — Chart showing septic infection after operation. (Excision of cystic tumor of 
breast, local abscess. > i Chart by Miss Virginia Ryan.) 



INFECTION IN WOUNDS 41 

in all but one particular. The new-formed tissue resulting 
from the healing process is still soft and easily torn. What 
we may call the solidification of the new tissue is not com- 
plete until two or three weeks have passed. The final visible 
result is a scar, a bond of new-formed fibrous or connective tissue 
solidly uniting the wound surfaces, and appearing as a narrow 
line along the site of the incision. At first the scar is of a red or 
purple color, owing to the presence of numerous capillary blood- 
vessels, but this color gradually fades away, until after some 
weeks the scar appears much whiter than the surrounding skin. 

IV. INFECTED WOUNDS 

There are many varieties of single-celled organisms capable 
of giving rise to disease, which can make use of an open wound as 
a portal of entry into the body, but when we speak of infection 
in wounds we ordinarily mean septic infection; that is, an invasion 
by certain species of bacteria which cause, when growing in the 
tissues, a local diseased condition, known as sepsis, characterized 
by inflammation, delayed healing and the formation of pus, 
together with constitutional disturbance or general illness, the 
most prominent symptoms of which are high fever, chills, pro- 
fuse sweating, and digestive disturbances. 

When an operative wound has been infected with the bacteria 
of sepsis, the course of events will be somewhat as follows. For 
the first two or three days there will be no disturbance, the condi- 
tion of the patient being the same as in normal healing. On the 
third or perhaps the fourth or fifth day there will be a sudden 
rise of temperature, of probably from three to five degrees, 
making its appearance usually in the afternoon. There will be 
an increase in the pulse rate. There may be a sharp chill or slight 
chilly sensations, known as rigors, followed by more or less 
profuse sweating. Pain in the wound will be present, and may 
have been complained of before the fever appeared. On the 
following morning the temperature will be found to be nearly 
or quite normal, but in the afternoon it will again rise to a higher 
level than before, and the other constitutional symptoms that 
have been referred to, together with digestive disturbances and 
restlessness, will be increasingly manifest. This type of fever 
with a sharp rise in the afternoon and a drop to nearly normal in 
the morning is quite characteristic of septic infection, although 
in many cases the fever is more continuous in character and often 



42 INFECTION 

irregular (Fig. 14). When the dressings are removed and the 
wound is exposed to view, a characteristic appearance will present 
itself. The tissues in the neighborhood of the wound ma}' be 
markedly swollen, rendering the skin stitches quite tense. The 
skin about the incision will be of a bright red color unless the 
infection has begun in the deeper part of the wound and has not 
yet extended to the surface, in which case there msiy be little 
change in the color of the skin. To the touch the tissues about 
the wound will be distinctly warmer than other parts of the body 
and the wound itself will be exquisitely tender. These symptoms, 
swelling, redness of the skin, heat and pain, are the so-called car- 
dinal signs of inflammation, which is usually denned as a condi- 
tion entered into by the tissues as a result of irritation, in this 
case from the presence of septic bacteria. When the stitches have 
been cut the edges of the wound will readily separate, allowing 
the escape of a more or less abundant discharge of a pale yellow 
fluid material, of a creamy consistency and a pasty odor, known 
as pus. When a wound discharges pus it is said to be suppurating. 
The color and consistency of pus are due to the presence of enor- 
mous numbers of leucocytes, which have found their waj T into 
the wounded tissues through the walls of the blood-vessels. They 
seem to be attracted to the locality by the presence of the invading 
organisms, and moreover the number of leucocytes in the blood 
increases in cases of septic infection sometimes to as much as 
five or six times the normal number. When the exudate in an 
infected wound has the character of pus it is said to be purulent. 
The character of the exudate varies considerably in different 
cases. If very few leucocytes are present, it may be thin and 
watery and it is then described as a serous or, if blood stained, 
as a serosanguineous exudate. If coagulated fibrin is present in 
considerable quantity it is spoken of as a fibrinous exudate. 

The growth of septic bacteria within the body often results 
in the death of many tissue cells and a breaking down and lique- 
faction of tissue in the infected area so that a cavity is formed 
which becomes more of less rapidly distended with an exudate, 
usually of a purulent character; that is, one containing an enor- 
mous number of leucocytes. Such a cavity containing pus is 
called an abscess. 

There are thus to be found both local and general symptoms 
and signs in septic disease due to wound infection. The local 
disturbances known as inflammation and suppuration are due 



INFECTION IN WOUNDS 



43 



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44 INFECTION 

to the direct irritation of the tissues by the invading bacteria 
and their toxic secretions. The general or constitutional symp- 
toms of fever, chills, sweating, digestive disturbances, and so on, 
are caused by the absorption into the blood stream of poisonous 
chemical products derived from the infecting organisms and from 
the dead tissue cells in the infected area. When provision is 
made for free escape of the exudate containing these products 
the poison is no longer absorbed into the blood and the symptoms 
due to its presence are promptly relieved. When, for example, 
an abscess either ruptures spontaneously or is laid open by an 
incision with the knife, the escape of the pus which has been 
confined within it is followed by almost instant fall of the tem- 
perature to normal and the disappearance of other symptoms 
which accompany the fever. The treatment of septic infection 
therefore is drainage, and when this can be satisfactorily accom- 
plished the chances of recovery are greatly increased. 

V. HEALING IN INFECTED WOUNDS 

The healing of an infected wound appears to follow a very 
different course from that which has been described for a clean 
or aseptic wound, although in reality the processes involved are 
essentially the same. The time required is much longer, for not 
only does the presence of the invading cells effectually retard 
the process, but the necessity for drainage of the wound frequently 
requires that all the stitches shall be removed and the wound 
allowed to gape widely open, so that a very much larger amount 
of new tissue has to be formed to fill it up. This new-formed 
tissue is known as granulation tissue, a name which is derived 
from the characteristic surface appearance of the growth. The 
color of this granulation tissue is a bright red, and the surface 
is not smooth but granular, showing many small elevations of 
uniform size, each elevation representing a capillary loop. The 
tissue consists of young connective-tissue cells and newly formed 
capillary vessels, the same in character as those which form to 
unite the edges of a clean wound which is undergoing normal 
healing with the cut surfaces in contact. A gaping open wound 
heals by filling up from the bottom with granulations until they 
are level with the surface, after which the new-formed epithelial 
cells growing in from the edges gradually cover the wound. 
Granulations are soft and easily torn, bleeding readily on the 
slightest touch, but the unbroken surface offers an almost im- 



INFECTION IN WOUNDS 45 

pervious barrier against the entrance of infecting organisms, and 
slight injuries are rapidly repaired, so that a granulating wound 
is comparatively safe from infection. 

The severity of septic infection in a wound may vary in every 
degree from a superficial and insignificant " stitch abscess " to a 
rapidly fatal general infection. By the latter term we mean that 
the bacteria have found their way into the general circulation 
and are growing everywhere in the body instead of being confined 
to one locality. Several terms commonly used in relation to 
septic infection may now be defined. Septicaemia means that 
the blood contains poisonous products of bacterial growth 
absorbed from some local infection. Pyaemia is the older term 
used to indicate the presence of septic bacteria in the blood. 
Since, when bacteria are to be found in the circulation their 
poisonous products must be present also, the word septicopyeemia 
is the more modern term used in describing this condition. 

VI. THE SOURCES AND MODES OF SEPTIC WOUND INFECTION 

In the early days of antiseptic surgery it was assumed that 
the air was the source from which the germs of sepsis came. 
Later it was recognized that septic infection of operative wounds 
rarely came from the air, but almost invariably from contact, 
the bacteria being carried in by anything that touched the 
wounded surface. The conception then was that all material 
objects, our own bodies included, of course, were resting places 
for septic bacteria, which gradually accumulated upon them from 
the air, although the air itself contained comparatively few at 
any one time. This conception revolutionized our operative 
technic, bringing in the era of so-called aseptic surgery. It was 
nearly enough true to enable us to develop our technic to a 
high degree of efficiency. But to understand the real situation 
it is necessary to go one step farther. It is a fact that all material 
objects in daily use about us are, as a rule, the bearers of living 
bacteria of the kind that cause septic disease, but why? The 
reason is that we have handled them, breathed upon them, 
sprinkled them with mouth spray, silted them with dust rubbed 
from the surface of our bodies or derived from its dried secretions. 
The human body, healthy or not, is the reservoir from which 
comes the ever-present supply of septic organisms. Material 
objects are contaminated in proportion as we handle them. In 
the great world of out of doors, the air, the water, the soil, and 



46 INFECTION 

vegetation, living or decaying, are comparatively free from the 
germs of sepsis. Every human being is a chronic carrier of the 
organisms of septic disease. Operative wounds are infected by 
human contact, direct or indirect, and the same is true of acci- 
dental wounds. In many of these, infection takes place not at 
the time of injury, as we are accustomed to suppose, but by care- 
less handling afterward. The same rigid precautions should be 
exercised in dealing with them as in the case of operative wounds. 

VII. THE BACTERIA CONCERNED IN WOUND INFECTION 

The vast majority of cases of septic infection in wounds are 
due to the action of only three or four distinct species of bacteria. 
There are a number of other occasional invaders, but they are 
so rare that they need not be mentioned here. 

1. Staphylococcus Pyogenes (Fig. 15). — This organism is the 
most common cause of septic infection, being found in probably 
eighty per cent, of the cases. The individual cells are minute 
globular bodies (cocci), and they appear under the microscope 
in irregular masses, suggesting a bunch of grapes to their first 
observers, who named them in accordance with this character- 
istic. Ci Pyogenes^ meaning pus-producing, was added to the 
name to distinguish the species from other staphylococci which 
do not cause disease. A third name is added to indicate one of 
several varieties or allied species, and this is usually suggested 
by the color of the growth on artificial culture media. Aureus 
(golden yellow) and albus (white) are the most common forms. 
These bacteria grow abundantly on all our culture media, either 
in the presence or absence of air. They retain their vitality in the 
dried condition for a considerable time, and are rather resistant 
to chemical disinfectants and to heat. Boiling water kills them 
within a few minutes. Abundant formation of pus is character- 
istic of the infections with which they are concerned. The 
Staphylococcus pyogenes aureus is the variety usually found in the 
more severe infections, and the albus in milder cases. This 
organism is very often present on the skin, in the mouth, and in 
the intestines of healthy individuals, one variety of the Staphylo- 
coccus albus being a quite constant inhabitant of the human skin. 
2. Streptococcus Pyogenes (Fig. 16). — This organism holds 
the second place in point of frequency among the bacteria of 
sepsis. From another standpoint it might be regarded as of 
first importance, since on account of its extreme virulence in 
some cases it is more to be dreaded than the staphylococcus as a 



INFECTION IN WOUNDS 47 

cause of wound infection. The most rapidly fatal forms of infec- 
tion are due to this cause. The streptococcus appears under 
the microscope in the form of short chains, which look like 
strings of beads. It is this peculiarity of arrangement that enables 
us to distinguish it readily from the staphylococcus, since the 
individual cells of each species look almost exactly alike, appearing 
to the eye under the microscope as very small spherical bodies. 
It is easily cultivated on our culture media, growing best at 
about the body temperature and in the presence of air. It is a 
rather more delicate organism than the staphylococcus, dying 
out rapidly under conditions that are unfavorable to it. The 
character of the inflammation which it produces in the tissues 
differs from that caused by the staphylococcus. There is less 
tendency to the formation of pus and the production of abscess 



ir&Y-ft\ I *0^ 









f * s 



* A. 1 . i : \ 



/y*rz 






Fig. 15. — Staphylococcus Fig. 16 — Streptococcus 

pyogenes (Carr). pyogenes. 

i '"■•.£-.. - ■ --* : . • • 

cavities. The- exudate is more serous or watery in character, 

and tends to infiltrate the tissues and to extend rapidly. This 
organism is also the cause of erysipelas, and is found in the 
majority of cases of puerperal fever. It is frequently present in 
the mouth and intestinal canal in both man and lower animals. 
Great variation in virulence is one of its marked characteristics. 
It is for this reason perhaps that in spite of its wide distribution 
infection with the streptococcus is fortunately less common than 
infection with the staphylococcus. When it does occur it is 
regarded as the most serious of all the forms of septic infection, 
and in some cases its virulence probably surpasses that of any 
other organism known. In every case of erysipelas or other form 
of streptococcus infection occurring in a hospital the most 
extreme precautions must be taken lest these deadly germs be 
conveyed to healthy wounds either at an operation or at a re- 
dressing. 



4^ INFECTION 

3. Bacillus Coli Communis (Fig. 17). — A number of closely 
allied species or varieties are included under the name of colon 
bacilli. These organisms are normal inhabitants of the large 
intestine, and form the largest part of the bacterial content of 
fecal matter. They appear as short, thick rods with rounded 
ends. Some varieties possess motility and some do not. None 
form spores. They grow readily on culture media either with 
or without the presence of air or oxygen. They withstand drying 
well, but are not highly resistant to heat or chemical disinfec- 
tants. They are pus producers and are the most common organ- 
ism found in cases of peritonitis due to perforation of the intestine 



:-- ...;.V 




r~ * 



Fig. 17. — Bacillus coli communis, showing Fig. IS. — Bacillus pvocvaneus, showing 
flagellar (Gray). flagellar (G: 

with escape of its contents into the abdominal cavity, although 
probably always associated in these cases with pyogenic cocci. 
In operative wounds, the colon bacillus is sometimes the cause of 
infections, which are. however, not usually of a very severe grade. 
4. Bacillus Pyocyaneus (Fig. 18). — The bacillus of green pus 
is an occasional invader in operative wounds and is usually asso- 
ciated with the staphylococcus. When it is present, the pus 
discharged from the wound assumes a peculiar bluish-green color, 
for which the organism is named. It is a small, rod-shaped organ- 
ism (bacillus', provided with flagellar at each end, and is very 
actively motile. It grows readily on culture media, where it 
produces its characteristic pigment. It is often present on the 
skin and in the intestines of healthy human beings. It does not 
form spores. 



INFECTION IN WOUNDS 49 

VIII. OTHER INFECTIONS OF IMPORTANCE IN SURGERY 

The bacteria already described include those which are com- 
monly found as the cause of septic infection in operative wounds. 
It is not a complete list, but others, being of less frequency and 
importance, need not be enumerated here. There are a number 
of other organisms which are able to use a wound anywhere in 
the skin or mucous membrane as an avenue of entrance to the 
body, and which give rise to a variety of diseases which are not 
properly classed as septic. Two of these must be enumerated 





Fig. 19. — Bacillus tetani, showing flagellar Fig. 20. — Bacillus tetani, showing spores 

(Gray). (Carr). 

on account of the deadly character of the diseases caused by them, 
although both are fortunately rare invaders in operative wounds. 
1. Bacillus Tetani (Figs. 19 and 20). — The tetanus bacillus, 
the cause of the disease commonly known as lockjaw, is a small, 
slender bacillus, actively motile by virtue of numerous flagellse 
which it possesses. Each bacillus produces a spore at the end 
of the rod, giving it a characteristic appearance resembling a 
drumstick. It is a strict anaerobe, growing on culture media 
only when every particle of oxygen is rigidly excluded. The 
spores of this organism are exceedingly resistant to heat and 
chemical disinfectants. Boiling for an hour or more in water 
is barely sufficient to kill them, and they survive immersion in 
powerful disinfecting solutions for many hours. They are found in 
the soil, particularly about horse stables, being a frequent inhabi- 
tant of the intestines in horses, cattle, and sheep, and even in man. 
This organism produces a powerful toxin which has a selective 
action upon certain groups of cells of the nerve centres. Tetanus 
4 




50 INFECTION 

infection results in death in the great majority of cases. It occurs 
most frequently in accidental wounds contaminated from the soil. 
2. Bacillus Aerogenes Capsulatus (Fig. 21). — The gas bacillus, 
as it is commonly called, is a large bacillus surrounded by a 
capsule. It is not motile, and is strictly anaerobic, the smallest 
amount of oxygen or air preventing its growth entirely. It forms 
spores and is therefore highly resistant to drying and heat. In 
its growth it produces a large amount of gas, and in the tissues of 
the body when infected by it this is manifested by great disten- 
tion, causing a tight stretching of the skin over the part, and by 
a crackling sensation felt and heard when the finger presses on 
the skin, due to the presence of gas in the intercellular spaces. 



■ -.' T 
J v. 

t S> 

Fig. 21.— The gas bacillus. Fig. 22.— Tubercle bacilli (Carr). 

It is a widely distributed organism, being a common inhabitant 
of the digestive tract, and is frequently found in water, soil, and 
dust, but fortunately it is rarely a successful invader of the human 
body. It is, on the other hand, an exceedingly fatal infecting 
agent when once it has become established. 

Finally, brief reference must be made to three forms of infec- 
tion which call for special attention, not so much as possible 
invaders in operative wounds as because of their wide prevalence 
and great surgical importance. 

3. The tubercle bacillus (Fig. 22) (Bacillus tuberculosis) is a 
slender, non-motile organism which does not produce spores. It 
is cultivated with difficulty in artificial media, growing in the 
presence of air but very slowly and only under special conditions. 
Special staining methods are also required to make it visible for 
microscopic study. Its invasion of the body gives rise to a great 
variety of diseased conditions, involving nearly every tissue and 



INFECTION IN WOUNDS 51 

organ. The forms of tubercular disease which are amenable to 
surgical treatment are mainly those which affect the bones, 
joints, and lymphatic glands. Many cases of undoubted infec- 
tion with this organism through operative wounds have been 
noted, but this mode of infection is so easily under control that 
it can only occur as the result of gross ignorance or carelessness. 
The usual mode of infection is either through the respiratory or 
alimentary tract. With the exception of the two diseases to be 
mentioned in the following paragraphs, tuberculosis is probably 
the most prevalent disease to which man is subject. The sources 




Fig. 23. — Trepomena pallidum (Gray). 

and modes of its invasion are not yet thoroughly understood, 
and the question of its control is one of the great problems of 
preventive medicine. 

4. The organism which is the cause of syphilis {Treponema 
pallidum) (Fig. 23) is a slender, corkscrew-shaped rod, actively 
motile and possessing flagellar, but it probably belongs to the 
class of protozoa, or single-celled animals, rather than to the 
bacteria. It finds its portal of entrance into the body almost 
always through slight surface wounds of the skin or mucous 
membrane. Like the tubercle bacillus it is not a serious menace 
to the work of the operative surgeon, and for the same reason. 
The diseased conditions caused by syphilis, like those of tuber- 
culosis, are of great variety and may involve any tissue or organ. 



52 INFECTION 

The most prominent manifestations are ulcerations of the skin 
and mucous membranes, and the destruction of tissue cells in 
extensive local areas in different internal organs. Cases of this 
disease are always to be found in the wards of a hospital, often 
associated with other surgical conditions. A thorough knowledge 
of its infectious character is essential for the nurse on account of 
its wide prevalence and the grave character of the disease itself. 
The organism is, in the vast majority of cases, conveyed through 
direct contact with an infected person, though infection by indi- 
rect contact may occur, as for example by means of a public 
drinking cup, or any contaminated utensil handled by an 
infected person. The organism, however, does not long survive 
outside the bod}' and is readily killed by the ordinary means of 
disinfection. The secretions from the 
ulcerative lesions are particularly infec- 
tious. 

5. The organism of Xeisser (gonococ- 
cus) (Fig. 24) is a diplococcus, appearing 
under the microscope as two incomplete 
spheres with flattened surfaces in contact. 
It is a pus-producing organism and there- 
Fig l 2i -7^ 1 A QT ^ oc ^ n %r £ onor - fore belongs in the class of septic bacteria, 

rhceae (F. C. Wood, M.D.). ...,,, „ 

but it is considered here apart from the 
others in order to emphasize its role as a cause of disease requir- 
ing surgical treatment rather than its insignificant importance 
as an infecting agent in operative wounds. This organism has 
a special affinity for the mucous membranes, particularly of the 
genito-urinary tract and of the eye. The serous membranes are 
also susceptible to it. Mam T cases of pelvic disease in women are 
caused by extension of this form of inflammation through the 
uterus and Fallopian tubes. It has been estimated that this organ- 
ism is responsible for eighty per cent, of deaths from inflammatory 
diseases peculiar to women, and for sixty per cent, of all the work 
done by gynaecologists. The serous membranes lining the joints 
may be infected (gonorrhceal rheumatism) , the diplococci being 
carried to them by the blood stream. The eyes of infants born of 
infected mothers are frequently involved, resulting in blindness in 
neglected cases (conjunctivitis neonatorum). In adults also destruc- 
tive inflammation of the eyes may occur from this form of infection. 
This organism is very delicate, dying out in a few hours outside the 
body and being easily killed by disinfectants and by a compara- 
tive^ low degree of heat. 




PART II— THE FIELD OF SURGERY 



CHAPTER IV 

SURGICAL PATHOLOGY 
I. DEFINITIONS 

1. Affection. — Any structural change or abnormality in a 
tissue or organ or part of the body with a resulting alteration in 
the functional activity of the part involved is an affection. An 
affection may or may not be the result of disease, and it may or 
may not be the cause of disease. For example, an alteration in 
the convexity of the crystalline lens with resulting disturbance 
of vision is an affection of the eyes and not a disease. The affec- 
tion in this case is not produced by disease and does not give 
rise to any diseased condition, except perhaps through the effect 
of eye-strain upon the nervous system. A shrivelled valve in the 
heart, with resulting obstruction to the onward flow of the blood, 
or regurgitation from imperfect closure of the valve, is an affec- 
tion of the heart and not a disease. In this case, however, the 
affection is the result of disease, namely, an endocarditis occurring, 
for example, in the course of an attack of rheumatism. It also 
is likely to become sooner or later a cause of disease in distant 
organs, particularly the kidney, by reason of the . disturbance it 
produces in the circulation of the blood. An affection which is 
caused by a disease may be transient, passing away with recovery 
from the disease, or it may persist for a certain time after recovery, 
or it even may be permanent. 

2. Disease is an active process depending essentially on 
altered activities of some of the cells of the body due to the pres- 
ence of abnormal stimuli. The cells are thus impelled, not to do 
new things, but to do too much or too little of the things they 
normally do, and the harmonious interplay of their activities is 
interfered with. All the cell faculties may be affected, nutrition, 
oxidation, secretion, and reproduction. The death of some cells, 
the active reproduction of others, and profound nutritional 
changes in still others give rise to visible tissue alterations, 
which we know as organic changes, and these in turn may become 
the basis of an affection. 

When disease gives rise to structural change in any tissue of 

55 



56 THE FIELD OF SURGERY 

the body, we speak of it as an organic disease. When altered 
cell activities are present without recognizable tissue changes, we 
speak of the disease as functional. 

An acute disease is one of sudden onset and short duration, 
measured by days or weeks. A chronic disease is one of long 
duration, measured by months or years. A chronic disease may 
have an acute onset. There is, of course, no exact time limit, and 
subacute or subchronic are used as intermediate terms. A disease 
may be local or topical, or it may be general or constitutional, 
according as the disturbance involves a part only or the whole 
body. A complication is a disturbance occurring during the 
course of a disease, arising from a cause wholly or in part different 
from that of the disease itself. Sequelae are the late and remote 
effects following an attack of disease. Specific disease is a term 
which, though susceptible of a wider meaning, is commonly used 
as a synonym for syphilis or lues. 

3. Etiology means the study of the causes of disease. An 
important distinction is made between a predisposing cause, or 
one which renders an individual more susceptible to an attack 
of disease without actually producing it, and an immediate or 
exciting cause. Exposure to cold is a predisposing cause of 
pneumonia; the exciting cause is the invasion of the pneumo- 
coccus. The exciting causes of disease are those agents which 
give rise to the abnormal stimuli acting on the body-cells. They 
may be mechanical, chemical, physical, or living agencies inimical 
to the cell, or disease may be caused by the absence or the pres- 
ence in excess of substances normally used by the cell. The 
interaction of stimuli between the groups of cells, which make up 
the glands and other organs, plays a role of great importance in 
the complex manifestations of disease. 

4. A lesion is any organic tissue change. Various types of 
lesions are given special names. Hypertrophy is overgrowth or 
increase in bulk of a cell or tissue. Atrophy is shrinking or 
wasting. Necrosis is the death of the cells of a part of the body. 
Degeneration is a term used to describe many forms of nutritional 
changes in the cells resulting in partial or complete loss of their 
normal activities. Regeneration is the rebuilding or renewal of 
normal tissue cells. Cicatrization is the filling of a defect with 
fibrous or scar tissue, such as occurs in the healing of wounds. 
Infiltration is the distention of the spaces between the cells with 
fluid or with other cells, such as the leucocytes. Metaplasia or 



SURGICAL PATHOLOGY 57 

heteroplasia are different forms of a rare condition, namely, the 
growth of normal tissue in the wrong place, as the growth of 
bone in tendon, cartilage, or muscle. Neoplasia is the formation 
of new-growths or " tumors " (neoplasms). 

Local functional disturbances occur without alteration of 
tissue structure. Hyperemia is an increased flow of blood to a 
part. Passive congestion is a damming back of the blood in a 
part. Stasis is a checking of the blood flow. Local anaemia is a 
diminution of the normal amount of blood in a part. Anaesthesia 
of the skin is a loss of sensation in a local area. Hyperaesthesia 
is an increased sensitiveness to touch and pain. 

5. Symptom. — A symptom is any recognizable manifestation 
of disease, or of altered function resulting from an affection. 
When a symptom is manifest only in the consciousness of the 
patient, it is called a subjective symptom; when it is manifest 
in any manner to the observer as well as to the patient, it is an 
objective symptom. Thus nausea is a subjective symptom; 
vomiting is an objective symptom; pain is a subjective symptom; 
the observable manifestations of pain, the cry, the facial expres- 
sion, the shrinking from pressure on the painful area, are objective 
symptoms. 

A pathognomonic symptom is one which is known to indicate 
one particular disease condition and one only. A premonitory 
or precursory or prodromal symptom is one which tells us before- 
hand what is going to happen. They are, in other words, the 
earliest manifestations of disease which appear before the disease 
condition has developed sufficiently to be recognizable. Local 
or topical symptoms are those which occur in a particular part 
or organ of the body. General or constitutional symptoms are 
those which cannot be referred to one locality, such, for example, 
as fever, restlessness, or insomnia. Symptoms may be classified 
according to the part of the body in which they are present, as, 
for example, abdominal symptoms, gastric, renal, or pulmonary 
symptoms. Or, they may be classified according to the physio- 
logical system involved, as respiratory, circulatory, digestive, 
sensory, or motor symptoms. A localizing or focal symptom is 
one which indicates the exact locality of a lesion, particularly 
in the brain or spinal cord. A consistent group of symptoms 
characteristic of a particular disease condition is spoken of as a 
symptom-complex or syndrome. 

6. Physical signs are the recognizable manifestations of 



58 THE FIELD OF SURGERY 

structural or organic change, that is of an affection. They are 
always objective in character and in many cases can be recog- 
nized only by a skilled and practised observer. 

Physical signs are recognized by the senses of sight, touch, and 
hearing. By inspection we note the general condition of the 
patient as regards nutrition, the presence of altered contours of 
the body, local swellings, changes in the color or texture of the 
skin and mucous membranes, motor disturbances, the facial 
expression, and so on. By palpation we learn through the sense 
of touch whether any part is harder or softer than normal, the 
size, shape and mobility of tumors, the presence of fluctuation 
indicating fluid, and of areas that are painful on pressure. By 
manipulation we detect limitation of motion in joints, abnormal 
points of motion such as occur in fractures, and so on. In men- 
suration we use the tape line to obtain exact measurements, 
usually comparing the two sides of the body. The sense of hearing 
is used in auscultation to determine the character of sounds 
within the body, principally in examination of the heart and 
lungs. In percussion the ear detects differences in the resonance 
or sounds produced by a blow with the fingers upon the surface 
of the body. This is used almost exclusively in examination of 
the chest and abdomen. 

7. Signs. — The word sign is used to describe certain single 
symptoms or physical signs, usually elicited by some special 
manipulation or procedure, and supposed to be pathognomonic 
of some particular disease or affection. Many of these signs have 
not proved to be susceptible of any rational explanation, but 
have been observed to be present more or less constantly in cases 
of the disease in question. Very many such special signs have 
been described, of varying value and importance, and they are 
usually known by the name of the discoverer. For example, 
Kernig's sign in spinal meningitis consists in the fact that the 
knee cannot be fully straightened when the thigh is placed at 
right angles to the trunk. Graefe's sign in exophthalmic goitre 
is the failure of the upper lid to move with the eyeball in glancing 
downward. 

Evidence of the greatest value as to the character of disease 
is also to be obtained by both chemical and microscopical exami- 
nations in the laboratory of the blood and the various excretions, 
particularly the urine, sputum, and faeces. 

8. Diagnosis and Prognosis. — Diagnosis is the act of deter- 



SURGICAL PATHOLOGY 59 

mining the character of a disease and of the lesions and affections 
produced by it. Described in the crudest form, it is the act of 
distinguishing one disease from another. Prognosis is the esti- 
mation of the probable course, duration, and outcome of a disease. 
Diagnosis in many cases is a complex and difficult problem, for 
the manifestations of disease are very variable, the physical signs 
often obscure, and many symptoms or even groups of symptoms 
may arise from widely different causes. Clinical diagnosis is 
that based on the symptoms of the disease, physical diagnosis 
is based on the physical signs. Pathological diagnosis is that 
based on an examination of the tissues and organs after death. 
Differential diagnosis is made by contrasting the symptoms and 
physical signs of two diseases that are liable to be mistaken for 
each other. A presumptive diagnosis is one based on a few 
prominent symptoms. A provisional diagnosis is one made with 
a mental reservation, to be changed if further evidence presents 
itself. 

9. Treatment is the application of any measure designed to 
assist in bringing about the cure of disease, or relief of its symp- 
toms, or to correct a disturbance of function arising from an 
affection. Therapeutics or therapy is the general term for all 
forms of the treatment of disease. Empirical treatment is any 
form which we have learned by experience to be efficacious with- 
out knowing the reason why. Rational treatment is that based 
upon reasoning from the known facts about the disease or its 
causation. Treatment is spoken of as radical when it is directed 
to the removal of the cause of the disease, symptomatic when 
its object is the relief of the symptoms only without any attempt 
to remove the cause, palliative when it is not expected to cure 
the disease but only to hold it in check, supporting when it is 
mainly directed to sustaining the strength of the patient. Specific 
treatment is the use of a single remedy which has a definite 
curative action upon a certain disease; for example, quinine in 
malaria, mercury and salvarsan in syphilis, diphtheria antitoxin 
in diphtheria. In the treatment of disease it is quite as important 
to know when to let nature alone as when to try to aid her, and 
this attitude is expressed by the term " expectant treatment." 
Active treatment, on the other hand, consists in the vigorous use 
of strong remedies. 

10. Pathology is the science which treats of the changes that 
take place in the body as the result of disease. It deals both with 



60 THE FIELD OF SURGERY 

alterations of appearance and structure in the tissues and organs, 
and with disturbances of function in various parts of the body 
mechanism. The causes of disease also come within its scope in 
finding an explanation of the manner in which different harmful 
influences act upon the body. Gross pathology, or pathological 
anatomy, treats of changes in the tissues that are visible to the 
naked eye. Pathological histology, or cellular pathology, is con- 
cerned with changes in the individual cells as seen under the micro- 
scope. Changes in the body functions resulting from disease 
constitute a very important part of pathological study and this 
department is described by the rather awkward term "pathological 
physiology." Surgical pathology is the pathology of surgical con- 
ditions; i.e., of those diseases and affections which are amenable 
to surgical treatment. This latter is obviously a very artificial 
subdivision. Pathological processes are not capable of separate 
classification according to the methods of treatment that happen 
to be applicable to them, but the term is convenient as designating 
a limited part of the field when discussed in surgical treatises. 

II. THE MEANING OF PATHOLOGICAL CHANGE 

Every pathological change is the result of changes in the activ- 
ities of some of the cells of the body, brought about by various 
forces which act as stimuli upon the cells. The normal body is 
of course the seat of incessant change, and very many pathological 
processes can be paralleled by changes which occur normally in 
the body. It is impossible to frame a concise definition of so 
complicated a subject that is not open to criticism, but a helpful 
point of view in understanding the meaning of pathological 
changes may be obtained if we say that the difference between 
health and disease consists largely at least in the fact that in the 
normal condition a certain balance is maintained in the activities 
of the cells, whereas in diseased conditions this balance is de- 
stroyed. Such a disturbance of balance manifests itself in a 
variety of ways. For example, the needs of the organism as a 
whole continually require that one or another group of cells shall be 
called upon temporarily for extra work. The organism is so consti- 
tuted that in such a case influences automatically arise which urge 
these cells on to work. When the extra work is done or is no longer 
needed other influences come into play which restrain the cells. 
Thus the organism {e.g., the human body) is able to carry on its 
functions normally in spite of changing environment, by what may 



SURGICAL PATHOLOGY 61 

be called a properly balanced adjustment of its cell activities. If 
either the urging influences (exciting stimuli), or the restraining 
influences (inhibiting stimuli), are increased or suppressed from 
any cause, then the cells either fail to do the work needed, or 
they continue in riotous and undisciplined activity. Examples 
of such disturbance in the equilibrium of cell activities are in- 
numerable in disease. In fevers the rise of temperature and the 
rapid heart action are manifestations of abnormal increase in 
cell activity, and the depressed secreting activity of other cells 
is seen in the dryness of the skin and mucous membranes. But 
a disturbed balance may be shown to be the cause not only of 
functional changes but of visible physical changes as well. Thus 
in the healthy body fluid is constantly leaking through the walls 
of the capillary blood-vessels into the spaces between the cells 
in the tissues. This fluid bathes the individual cells, furnishes 
them with nutriment, and carries off their waste products. 
Normally the fluid is carried off exactly as fast as it comes in, 
passing along the lymphatic channels, from which it eventually 
returns to the blood stream, while a part is thrown off in the 
form of excretions from the skin, kidneys, etc.; if, however, less 
is carried off than comes in, this fluid accumulates in the tissue 
interspaces; they become soggy with watery fluid, and we have 
a pathological condition known as oedema. Physical changes in 
individual cells are also due in many cases at least to a similar 
disturbance in balance. Thus every cell in performing work 
gives out energy, and in doing this it must use up some of its 
own substance in chemical change. This used substance must 
be replaced by an equal amount of substance taken into the cell 
from the material surrounding it. The work of the cell may be 
done quietly and almost continuously, or it may be done with a 
sudden explosive exercise of energy, as in a violent muscular 
exertion. In the latter case a period of rest must follow for the 
cell to restore the substance that has been used up. In either 
case an exact balance must, in the long run, be maintained 
between what is used up and what is taken in, if the cell is to 
maintain its normal life. If more is used up than is taken in 
the cell will waste away. If more is taken in than is used the 
cell will increase in size. In many chronic diseases particu- 
larly, alterations in the nutrition of cells give rise to a variety of 
transformations in cell substance which are known as degenera- 
tive changes. We know so little about the complex chemistry 



62 THE FIELD OF SURGERY 

of these processes that no general statement can properly be 
made in regard to them, but if these degenerative changes are 
due, as is possible, to an excess or insufficiency in some one 
link in a chain of chemical reactions normal to the cell, then we 
should have here also an example of altered balance as a cause 
of pathological change. 

III. THE CAUSES OF DISEASE 

All the causes of disease may be classified as either mechanical, 
physical or chemical in nature; i.e., every change in cell environ- 
ment must in the last analysis fall under one of these divisions. 
It is far from being true, however, that we are able to place all 
the facts known about disease causation in so simple a classifica- 
tion. Consider, for example, such problems as inherited abnor- 
malities, irregularities in nutrition, overwork and disuse, pre- 
disposition and susceptibility, the influence of sex, life period, 
occupation, etc.: these and many other factors in causation are 
so exceedingly complex in character that any simple systematic 
classification of them is quite impossible. We can consider here 
only some of the more obvious causes which give rise to conditions 
of disease. 

1. Mechanical Causes. — Trauma, or direct mechanical injury, 
is of course one of the most common causes of abnormal condi- 
tions of the body calling for surgical treatment. Wounds, frac- 
tures, dislocations, sprains, bruises, and a variety of internal 
injuries are produced by direct external violence. In all of these 
there is destruction of tissue cells, rending of anatomical struc- 
tures, always including blood-vessels, with an escape of blood 
externally or into the tissue spaces. The reaction of the tissue 
cells to such a local injury constitutes one of the most important 
parts of surgical pathology, and will be considered in a later 
paragraph. Mechanical pressure is a potent cause of harm, having 
many manifestations. The first effect of pressure upon a tissue 
is to squeeze out the fluid contained in it; the cells, being depend- 
ent upon the continuous flow of this fluid about them for their 
nourishment, die if it is withheld even for a few hours, and the 
result is therefore death of tissue in the compressed area: a 
condition called in this case sloughing or gangrene. Thus, if in 
putting up a fracture a splint is allowed to press too tightly upon 
the skin, particularly over a point where a bone lies near the 
surface, the result will be a sloughing of the skin and underlying 



SURGICAL PATHOLOGY 63 

tissue. Long-continued pressure not severe enough to shut off 
the circulation entirely has a different effect. The cells of the 
part undergo what is known as atrophy; i.e., they waste away. 
Even a solid tissue like bone will thus melt away by pressure 
atrophy from the presence of a growing tumor or an aneurism. 
On the other hand, pressure applied to a part not continuously 
but at intervals may stimulate cell growth and cause a thicken- 
ing on the part, as in corns and bunions on the calloused hands of 
the workingman. Many surgical conditions can be attributed 
to mechanical disarrangements within the body which are not 
due to external violence. For example, a strangulated hernia 
is due to a purely mechanical cause. A loop of intestine is 
pinched in the narrow neck of the hernial sac so that its circu- 
lation is cut off, with a resulting gangrene Unless relieved by 
operation. All the forms of intestinal obstruction, whether by 
adhesion bands, kinks, volvulus (twisting), intussusception (tele- 
scoping), impaction or the growth of a tumor, come under this 
head; so also do cases of obstruction in other tubular organs, 
such for example as the plugging of the outlet ducts of glands 
giving rise to retention cysts, or the shutting off of the flow of 
urine from the kidney to the bladder due to a stone lodged in 
the ureter. Displacements of abdominal organs due to relaxation 
of their supporting tissues (splanchnoptosis) give rise to a peculiar 
group of symptoms (Glenard's disease), including dyspepsia, 
constipation and neurasthenia. 

2. Physical Causes. — These include the effects of tempera- 
ture (heat and cold), light, electricity, X-rays, radium rays. The 
human organism is almost perfectly adapted to light of any inten- 
sity to which it can be subjected, and to a very wide range of 
temperature. The other forces mentioned rarely act as causes 
of disease. We need consider here only the effects of extreme 
degrees of heat and cold. Burns are classified as to severity in 
four degrees. In the first degree there is simple redness of the 
skin; in the second degree there is a separation of the superficial 
layers of the skin by effusion of serous exudate from the blood 
with the formation of blisters. In the third degree the deeper 
layers of the skin are destroyed, and in the fourth degree the whole 
thickness of the skin and part of the underlying tissue are charred. 
A second-degree burn of half the surface of the body or a third- 
degree burn of a much smaller area is always fatal. Healing of 
extensive burns of the third degree often gives rise to serious 



64 THE FIELD OF SURGERY 

deformities due to the contraction of the scar. The thermal 
death point of tissue cells is less than 130° F., so that water bottles 
which do not feel very hot to the hand may cause deep burns if 
left in contact with the skin of an unconscious patient for even 
a short time. 

Tissue cells are much less susceptible to destruction by cold 
than by heat. Local tissues, as of the hands or feet for example, 
may even recover after being frozen, provided that the thawing 
process is very gradual and that the brittle frozen tissues are 
not injured by manipulation. Frost gangrene occurs as a result 
of mechanical injury to the frozen tissue, and of too rapid thaw- 
ing leading to paralytic stasis of the circulation. On the other 
hand, the changes of temperature which the organism as a whole 
can survive are comparatively narrow. The reason is that any 
marked variation from the normal (or optimum) temperature 
inhibits cell activity, and if the action of certain cells, such as 
those which control respiration and the heart action, becomes 
suppressed death ensues. Thus a fall of the body temperature 
of even four or five degrees below the normal is apt to be asso- 
ciated with alarming symptoms of collapse, and a fall to ordinary 
room temperature (70° F.) is always fatal. In fever a rise of 
temperature to 106° F. is of grave omen: a rise to 109° F. is 
practically always fatal, though a few anomalous cases of higher 
temperature have been recorded. 

3. Chemical Causes. — Since the activities of living cells are 
so largely chemical, it is obvious that they are likely to be pro- 
foundly affected by any marked change in the character of the 
chemical substances which surround them. The word "poison" 
presents a familiar idea of the harmful effect of a chemical sub- 
stance upon a living organism. A change in the chemical en- 
vironment of a cell, like any other change, is spoken of, with refer- 
ence to its effect upon cell activity, as a stimulus, which must, as 
has been pointed out, influence a cell in one of two ways only, i.e., 
by exciting or inhibiting activity, although there may be first an 
increase and later a suppression of activity. Different kinds of 
cells are of course differently affected by any one chemical sub- 
stance, some being more susceptible to it than others. This fact 
is taken advantage of in medicine by the administration of vari- 
ous drugs with the purpose of increasing or diminishing one or 
another form of cell activity. Thus we relieve pain with mor- 
phine, suppress consciousness with ether, increase the secretions 



SURGICAL PATHOLOGY 65 

in the intestinal canal with cathartics, etc. Poison is therefore 
a relative term, since the harmful effect of a substance depends 
on the dosage and sometimes on other factors. Even distilled 
water is a deadly poison when introduced in quantity directly 
into a vein, whereas water containing from six- to nine-tenths of 
one per cent, of common salt (the so-called "normal" salt solu- 
tion so much used in surgery) has no ill effect. 

The poisonous substances which give rise to disease arise from 
various sources. They may be introduced from without, as with 
the food or drink or with the inspired air. They may be produced 
in the digestive canal by the fermentative action of saprophytic 
bacteria. Other poisons are produced within the tissues of the 
body by the secretions of invading pathogenic microorganisms. 
The disintegration of dead tissue cells, such as result from burns 
or other injuries or from disease, gives rise to poisonous substances. 
Finally the body may be poisoned by its own secretions, either 
by the reabsorption of retained excretions or by excessive activity 
of certain glands, or by the failure of the cells of some organ to 
do their part in the complex chemical changes which normally 
go on within the body. 

IV. CHANGES IN CELL ACTIVITIES 

The many kinds of cells which make up the various tissues 
and organs of the body are so interrelated in their activities that 
it rarely if ever happens that one set of cells can be deranged in 
their action without effecting changes in other groups throughout 
the body. The normal body is continually adjusting itself to 
changes in its environment, and the altered activities of cells 
which occur in disease are very often of the same kind as those which 
occur normally ; i.e., the organism is attempting to adjust or adapt 
itself to the abnormal situation, but in the case of a diseased con- 
dition with only partial success. Changes such as these may be 
called adaptive changes in the activities of the body- cells. 

On the other hand, certain groups of cells may be directly 
stimulated to an abnormal activity which has no adaptive quality. 
These we may call perverted changes in cell activity. It is, how- 
ever, by no means always possible to distinguish in diseased 
conditions between adaptive and perverted changes. 

1. Adaptive Changes. — These are very numerous in patho- 
logical conditions, and it is of the greatest importance to be able 
to understand as far as possible their significance. 
5 



66 THE FIELD OF SURGERY 

Examples of Adaptive Changes. — There is no sharp line be- 
tween the adaptive changes which occur in health and in disease. 
For example, the flushed face, the gasping breath and the quick- 
ened pulse which are manifest after a hard run or other muscular 
effort are adaptive changes which are seen also in scarcely altered 
form in such a disease as pneumonia and in other pathological 
conditions. The phenomena which accompany an attack of acute 
peritonitis furnish a remarkable example of the organism adapt- 
ing itself to an abnormal situation. Infectious material intro- 
duced from without or escaping from the intestinal tract at one 
locality within the abdomen would be rapidly spread throughout 
the peritoneal cavity by the movements of the intestinal coils 
which occur normally in the process of digestion, and by the 
action of the abdominal muscles. It is for the greatest advantage 
to the organism that such scattering of the infectious material 
should be prevented and that it should be confined as far as 
possible to one locality. All the phenomena which appear there- 
fore are such as will contribute to this end. The muscular walls 
of the intestines are paralyzed and motion of the coils ceases. 
Distention with gas increases the fixation of the intestinal coils. 
The abdominal muscles also are held with a board-like rigidity. 
Local pain and tenderness make a constant and imperative 
demand upon the attention to insure voluntary effort to keep 
this region quiet. If food is taken vomiting ensues to prevent its 
passage into the intestinal tract. Locally in the infected region 
inflammation is inaugurated, itself a notable example of adaptive 
change whereby the surrounding coils of intestine become ad- 
herent and the infected area is rapidly walled off from the sur- 
rounding parts. 

Compensatory changes are those whereby (a) one group of 
cells take up and perform the work of other cells (of the same or 
even of a different kind) which have been destroyed or whose 
function has been impaired; or (6) where certain cells increase 
their activity in response to a special need. Thus if one kidney 
is removed the other does double work and may increase in size. 
If the spleen is removed other organs, perhaps the lymph-nodes, 
take up its work and the animal continues in health. One lung 
can readily do the work of two. Hypertrophy of the heart 
muscle is an example of the second type of compensatory change, 
being adapted to overcome increased resistance at some point in 
the circulation. If a blood-vessel is obstructed other smaller 



SURGICAL PATHOLOGY 67 

vessels in the neighborhood dilate till they are able to carry the 
full volume of blood, forming what is known as the collateral 
circulation. 

Primary adaptive changes occur in an accidental or operative 
wound. When living tissues are divided by a wound a large 
number of blood-vessels (arteries, veins and capillaries) are 
severed, and this condition calls for the immediate inauguration 
of adaptive changes, which to be effective must serve two ends: 
first, to check the escape of blood, and, second, to preserve un 
impaired the flow of blood to the tissues which the severed 
vessels originally supplied. The first end is accomplished by 
changes in the blood resulting in what is known as clotting, 
whereby the fluid blood becomes changed into a firm jelly which 
plugs the vessels and checks the escape of fluid blood. This 
chemical change in the blood is a very complex one due to the 
giving off, from cells in the blood and from tissue cells, of certain 
substances which then unite with another substance dissolved in 
the circulating blood to form the fibrin that constitutes the clot. 
The second end is attained by the compensatory action already 
referred to, i.e., the dilatation of the adjacent vessels to carry 
on the blood stream into the area to which its flow has been inter- 
rupted. These two adaptive changes are essential conditions 
for the success of operative surgery. Without the first every 
wound would result in fatal hemorrhage. In practice it is neces- 
sary to assist nature by the temporary closing of the larger vessels 
by means of clamp and ligature until the clot has formed. This 
means of checking hemorrhage, however, is by itself of no avail 
when, as happens in certain individuals (bleeders), the clotting 
adaptation fails. Without the second adaptation large areas of 
sloughing tissue would result from every extensive wound. Such 
sloughing of tissue, more or less extensive, does in fact occur at 
times as the result of injudicious or unavoidable interference with 
the circulation by a surgical operation. 

Inflammation is defined as u the condition into which tissues 
enter as a reaction to irritation" or injury. It is an adaptive 
reaction of the greatest interest and importance which can only 
be briefly outlined here. The process can be actually seen at 
work in the classical experiment of placing the web of a frog's 
foot, or a portion of the mesentery drawn out of the abdomen, 
under the lens of the microscope, and irritating the surface of 
the tissue by a slight scratch (Figs. 25 and 26). Through the 



0> 



THE FIELD OF SURGERY 



thin transparent membrane the arteries, veins, and capillaries 
can be clearly seen with the blood stream flowing through them. 
The pulsating stream through the arteries is distinguishable, and 
the continuous flow through veins and capillaries. In the capil- 
laries the individual blood-cells or corpuscles can be seen as they 
pass in single file, but in the larger vessels these are seen only as 
a swiftly moving mass. The first change observed as the result 

Fm. 2S Fig. 26. 




Frog's mesentery, normal Frog's mesentery, inflamed. 

Figs. 25 and 26. — o, small vein; 66, dd, nerve-fibres; c, capillary; ee, connective tissue 
(in Fig. 12 filled with migrating leucoc; 

of the irritation is a dilatation of the i ith a more rapid 

flow of the blood stream: later the rapidity of the flow is dimin- 
ished and in places it becomes actually stagnant, with an occa- 
sional backward and forward motion of the mass of free blood- 
cells. Through the thin walls of the capillaries there is an escape 
of the fluid part of the blood which distends the spaces in the 
tissues between the blood-vessels. The cells of the blood, red 
and white, particularly the leucocytes, also make their way 
through the capillary walls and wander free in the tissue inter- 



SURGICAL PATHOLOGY 69 

spaces (Fig. 27). Later (this, however, is not readily visible in 
the living tissue) the local connective-tissue cells have their 
reproductive power stimulated, new ceils are produced and new 
capillary blood-vessels are formed. 

These changes seen in the frog's mesentery under the micro- 
scope readily explain the familiar phenomena of inflammation, 
with its cardinal signs of heat, redness, swelling and pain, as 
seen on the surface of our own bodies, for example in a boil. 
The redness of the skin and the local heat are due to the dilatation 
of the vessels and the consequent increased flow of blood to the 
part, while the swelling and pain are due to the great distention 
of the tissue interspaces with the inflammatory exudate. When 

T^4\>:' -'my, 

Fig. 27. — Emigration of leucocytes. The arrow shows direction of blood-current. (F. 

C. Wood, M.D.) 

mechanical injury alone is present, uncomplicated by bacterial 
invasion, the inflammatory reaction is relatively slight and under 
these conditions identical with the first stages of the healing 
process, to be presently described, whereby repair of the injured 
tissue is effected. When, however, septic bacteria have found 
lodgement in the injured tissues the reaction becomes greatly 
intensified; the amount of the exudate, both fluid and cellular, 
is largely increased, constitutional symptoms, including fever and 
other disturbances, appear, and the role of these adaptive changes 
becomes extended beyond the mere repair of the injury to an 
active defence against the action of the invading bacteria. 

The Healing Process. — The reaction by which injured tissues 
are repaired and the loss of tissue restored is an adaptation of 



70 



THE FIELD OF SURGERY 



vital importance to the organism and one that is almost constantly 
going on in some part of the body, as in the familiar rapid healing 
of superficial cuts and abrasions on the surface of the skin. It 
may therefore be considered a normal process when uncomplicated 
by conditions which retard it. such as infection. It is a highly 
efficient process within certain limits, but these limits are rather 
sharply denned. In general it may be said that only the sim- 
pler tissues are capable of restoration by the healing process. 
Highly differentiated cells of complex function, such as those 
of the central nervous system and the muscles, are incapable of 




round, 
filled with clot, the capillaries thrombosed on both sides; round-cell infiltration; be, sweat- 
gland; d, hair-follicle. (Shakespeare.) 



Fig. 28. — Section through skin of guinea-pig eight hours after a wound: a, the 

be 



restoration. When such cells which are incapable of restoration 
have been destroyed the gap is filled by new connective tissue, 
forming what is known as a scar. Healing is more rapid in the 
young than in the old, and in individuals with impaired health 
the process may be more or less retarded. We will consider 
briefly what takes place in the healing of a wound. 

The earlier steps of the process are those which have been 
described under inflammation. 

Whenever any tissue of the body has been wounded, the 
injury acts as a stimulus upon the cells of the part, calling into 
activity certain of their faculties, principally those of reproduction 






SURGICAL PATHOLOGY 



71 



and of motion. Several varieties of cells are thus set to work in 
the reparative process. The most active part appears to be 
taken by the connective-tissue cells, whose function it is to 
build up everywhere the solid framework of the body. The 
cells which form the capillary blood-vessels and the epithelial 
cells of the skin participate in the process, as do also in another 
way the free-moving white cells of the blood, or leucocytes. 

The first thing that happens is a temporary cementing or 
gluing together of the wound surfaces by the coagulated fibrin 
formed by the blood which oozes from the divided capillaries 
(Fig. 28). The connective-tissue cells on each side multiply 




Fig. 29. — The same at a later stage. The clots on the capillaries almost removed, new 
vessels forming towards the gap, new connective-tissue spindle-cells replacing the round 
cells. The epithelium has united on the surface. (Shakespeare.) 

by division, closing in the space between the wound surfaces 
with an interlacing mass of new cells. The cells which form the 
walls of the capillary blood-vessels increase in number, and loops 
of new-formed capillaries push across the gap to unite with 
similar loops from the opposite side (Fig. 29). The epithelial 
cells of the skin also have their reproductive powers awakened, 
though somewhat more slowly, new cells being formed which 
bridge the incision at the surface (Fig. 30). Meantime, beginning 
almost from the moment of the injury, the leucocytes are stim- 
ulated to more active motion and are attracted in large numbers 
to the wounded area. By virtue of their so-called power of 



72 



THE FIELD OF SURGERY 



amoeboid movement the}- force their way through the walls of 
the smaller blood-vessels and into the tissue spaces (Fig. 27 in 
the vicinity of the injury, where they exercise their ''phagocytic" 
power to eat up and carry fragments of dead tissue cells 

and other debris, including the fibrin which provisionally ce- 
mented the wound surfaces and even bacteria or other alien cells, 
if any have found their way into the wound. The secretions of 
the leucocytes also digest and liquefy the dead matter in the 
wound, and the absorption of fluid material passing into and 
carried away by the blood stream aids in the process of cleaning 




Fig. 30. — The same later. The gap filled with new connective tissue and young blood- 

5 h ikespeare) . 

up. By the end of the third to the fifth day the divided tise 
are practically reunited and there remains only to be accomplished 
the slower process of the formation of intercellular substances 
by the connective-tissue cells to consolidate the scar Fig. 31 . 

Healing I y granulation so called occurs where an open wound 
with wic - rated edges is filled up with new-formed tissue 
_ . The process is - ritially the same only with a more 
extensive formation of new tissue and a much slower accomplish- 
ment. 

ices of the Body Against Infection. — When an infection 
occurs a series of reactions within the body is inaugurated varying 



SURGICAL PATHOLOGY 



73 



with the character of the infection itself and also with other 
factors, such as the locality of the invasion and the powers of 
resistance of the individual. These reactions are partly adaptive, 
tending to protect the body from harm and to aid in its restora- 
tion to a normal condition, and partly also due to altered cell 
activities which have no adaptive quality. The weapons of attack 
of the invading cells are chemical in nature. It is by the poisonous 
products of the invaders that the tissue cells are injured. These 
harmful chemical products produced by the invading cells are 




Fig. 31. — Cicatrix formed in the wound, the young blood-vessels having disappeared 

(Shakespeare). 



of several kinds ; for example : (1) poisonous secretions extruded 
by the infecting cells known as toxins; (2) ferments or enzymes 
which have the power of disintegrating and dissolving living and 
dead tissue cells; (3) poisonous products resulting from the dis- 
integration of dead tissue cells or dead cells of the infecting 
organism. 

The symptoms or manifestations of infectious disease, the 
high fever, the chills, the digestive and nervous disturbances, 
the weakness and rapid emaciation, and sometimes the local 
signs of inflammation indicate a very profound derangement of 



THE FIELD OF SURGERY 



the normal functions of the body. Even to the most superficial 
observation there is a suggestion of a struggle between the disease 
and the forces that tend toward health, or. to speak more defi- 
nitely, between the cells of the body and the invading cells. The 
very fact that recovery ever takes place at all is in itself conclusive 
evidence of such a struggle. What. then, are the means of 
defence which the cells of the body are able to employ agiiL=: 
the invaders? 





f —£ & ; ''•-'■:■ 




s 5— . > :- - 

"° 'a* »*** -X N. ' s !_?:--- 



~0 v^\ ^^Vv""^. 




a 

7 : : • 2. — Healing of a wound by granulation: a, layer of fibrin, leucocytes, and detri- 

:u= :t-: ; _::'i :e : : sri-u'.iTi-rs: r ;:-:;;-: e;;r :-:' ^:::e:z;; :tL- :r:~ 5-::- : «>ir i: 
e-dz-E: :'—:_-£ : ir.i~ — _:;. = :~ - iz.f i~ ~ i::r.- L-il:n::: - -- ;. :> ^5t. :l z:rzii- 
:.^r_r :ir'i: l- ::; ;:r. :: .- :r:~ :r.:=^ ir. :ie ?ri- „:.:::- ::i.r_r: ;'. bl: :-:--r; fir'. :z '.s>"<e~ 
t^:::;:t T^rri":-; :ir:uzh ::= Tilli ; ne— :-:"e:~ve-u.5,r-e :r..f :i.tL :":r:- 
z ::--f :: in r;/i^:^. :^. ii:ji :"i ::ii:i::i_: • i:i :~: r-rli- :.- r r: :es= :: 
E trial » ; : . ~ — ing then rapid growth. (F. C. Wood, M.D.) 

These appear to be of two kinds : (1) those by which the alien 
cells are destroyed or their growth is checked, and (2) those by 
which the poisonous products of the infecting organisms are 
neutralized and rendered harmless. Thus the body-cells possess 
both offensive and defensive weapons in their battle with the 
invading enemies. There are two ways in which the infecting 
cells may be destroyed after they have entered the body. One 
is through the presence in the blood of substances which are 
poisonous to them. Such substances are normally present in 



SURGICAL PATHOLOGY 



75 



the blood; they are the result of chemical activities of the body- 
cells, and there is evidence that they are produced in increased 
amount as a result of the presence of the infection. 

The invading cells may also be killed by the direct attack 
upon them of certain of the cells of the body, which literally 




Fig. 33. — Varieties of colorless blood-cells seen in normal human blood: a, small lym- 
phocytes; b, large lymphocyte or mononuclear leucocyte; c, transitional leucocyte; d,' 
polymorphonuclear leucocytes; e, eosinophile; /, red cells. X 900. 

seize and devour them. Beside the highly specialized fixed cells 
which make up the various tissues and organs of the body, there 
are other cells which are not fixed, but detached and free, and 



Fig. 34. — Amoeba coli (Entamoeba dysenterise) , common form. X 400. 

are carried about in the ceaselessly flowing blood stream. These 
cells are of two kinds which exhibit a remarkable contrast in the 
character of their activities (Fig. 33). The red corpuscles of 
the blood are perhaps the most highly specialized of all the cells 
of the body. They can do one thing only, take up oxygen from 



7>? THE FIELD OF SURGERY 

the air and carry it to the tissue cells. They have lost all the 
other powers of the cell and even the most essential part of the 
cell structure, the nucleus. On the other hand, the white cells 
of the blood, or "leucocytes." appear to be the least differentiated 
and specialized of any of the cells. They retain all the activities 
that single-celled organisms possess. In their appearance and 
behavior they strikingly resemble certain forms of unicellular 
organisms known as amoeba? Fig. 34) which are found in stagnant 
water. These organisms have a peculiar method of movement, 
by a process of thrusting out a portion of the protoplasm of the 
cell body and of enclosing particles of food material which then 
become digested and dissolved. The cell folds itself about a 
solid particle of food material, much as one may wrap a piece 
of putty about a pea. Around the food particle within the cell 
body there then forms a small cavity or vacuole, into which there 
is apparently secreted from the cell protoplasm digestive juices 
which dissolve the food and prepare it to be assimilated. With 
reference to this faculty such ceils are designated by a name which 
signifies "cells that eat." They are called "phagocyte-" Fig. 
35 . The leucocytes possess this same power of amceba-like or 
amoeboid movement : and it is a part of their normal activities 
to take up and dispose of dead and waste and foreign material 
in the blood stream and tissue interspaces, and when infection 
takes place they exercise this phagocytic power upon the invading 
cells. They thus take up and destroy both dead and living 
bacteria and other organisms. This form of activity of the 
leucocytes, known as phagocytosis, is in many cases heightened 
during infection as a result of stimuli brought to bear upon them,, 
directly or indirectly, through the presence of the alien cells. 
There is a close relation between these two offensive means which 
the body-cells employ against infection, and together they play 
a most important part in the struggle. 

Another of the defensive activities of the body-cells is the 

formation of antitoxins, which, as we have indicated, do no 

harm to the infecting organisms, but render them harmless by 

neutralizing their poisonous secretions or toxins. The formation 

of antitoxin is also an example of the use of certain normal activi- 

:»f the body-cell as a means of defence against infection. 

A beautiful explanation of this is furnished by the celebrated 

-chain theory of Ehrlich. In the process of nutrition the 

must first seize upon the ultimate particles or molecules of 



SURGICAL PATHOLOGY 



77 



food substances and fix them to the cell, later incorporating 
them into the cell substance through chemical changes. It must 
be remembered that we are here dealing with the ultimate 
chemical structure of cell substance, which is infinitely below 
the limits of visibility. The actual manner of fixation, therefore, 
we cannot know, but must picture it to our minds in a somewhat 
crude mechanical form. 



12.45 




12.50 



12.55 



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fck) 




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ceased moving. 



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-w 



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Outline lost. 



1.15 

Fig. 35. — Phagocytosis. Destruction of a Plasmodium malariae by a. leucocyte in 
human blood. The figures indicate the time of observation, the whole process lasting 1 hour 
and 25 minutes. (F. C. Wood, M.D.) 

We may thus think of the molecules which make up the cell 
protoplasm as possessing little rods or chains projecting from 
their sides, each furnished at the end with a locking device of a 
certain shape exactly fitting a corresponding locking device 
attached to the molecule of food substance. To use a homely 
illustration, it is as if the two were supplied with a set of hooks 
and eyes of a special pattern. These side chains of the cell 
molecule are called receptors, or, to indicate their function of 



78 THE FIELD OF SURGERY 

fixing nutritious substances to the cell, nutrireceptors. Xow 
the toxin molecule is peculiar, in that it has a locking device of 
exactly the same shape as that of some variety of food molecule ; 
its eye fits the nutrireceptors hook, but the rest of its structure 
is wholly different from that of the food molecule. It is not 
only unavailable as food, but it is a deadly poison to the cell. 
When a toxin molecule has once become fixed to a receptor they 
cannot be separated, but the cell has one way left of getting rid 
of its dangerous incumbrances. It breaks off and sets free the 
receptors to which toxin molecules are attached. New receptors 
are then formed to take the place of those lost, and, by a well- 
known law of nature's bounty, they are formed in great excess 
over those lost. Many of the over-abundant, new-formed recep- 
tors are crowded off and become free in the blood stream. Here 
they encounter and fix the free toxin molecules before they have 
had time to reach the cells, thus rendering them harmless. These 
free and detached receptors in the blood form what we know as 
antitoxin. 

In all that we know about its powers of resistance against 
disease, there is nothing to suggest that the body is supplied 
with a special defensive mechanism designed or adapted for 
that purpose alone. What happens is that the cells are stimulated 
by the invaders to increase (or sometimes to decrease; certain 
activities that they are constantly exercising in the condition of 
health, activities of motion, of reproduction, or of chemical 
change, such as are normally concerned with the nutrition of 
the cell or with its oxidating or secreting power. 

Perverted Activities of Cells. — These are those which are 
due to the direct effect of abnormal stimuli exciting the cells to 
activity which has no adaptive uses. Notable examples are the 
convulsive seizures in tetanus and poisoning by strychnia. The 
thyroid gland is excited to over-activity (hypersecretion) in 
exophthalmic goitre (Graves's disease). In other cases its 
activity is depressed (hyposeeretion) . as in myxcedema. The 
formative or reproductive activities of cells are apparently per- 
verted in the case of rapidly growing tumors, particularly of the 
malignant type, and the same is true in certain infectious diseases. 
notably syphilis and tuberculosis, where there occurs a rapid 
proliferation of cells (hyperplasia) associated with degenerative 
changes. 



SURGICAL PATHOLOGY 79 

V. TISSUE CHANGES 

Activities of cells are of three kinds : (1) functional, (2) nutri- 
tive, (3) formative or reproductive. Increase or diminution of 
formative activities gives rise to tissue changes varying from 
microscopical lesions to gross anatomical alterations. 

1. Constructive Tissue Changes. — We have already con- 
sidered the constructive changes involved in the process of heal- 
ing or repair. Other examples of constructive change are seen 
in hypertrophy and in the formation of tumors. 

Hypertrophy. — Simple hypertrophy is an increase in the size 
of individual cells. Numerical hypertrophy is an increase in 
the number of cells of a part (hyperplasia). Examples of normal 
or physiological hypertrophy are seen in the uterus in pregnancy, 
in the breasts in laceration, and in the growth of muscles by 
exercise; adaptive hypertrophy in the increase of the heart 
muscle when called upon for continuous extra work from any 
cause, such as imperfection in the valves of the heart. When 
a part of the intestine is constricted for a long time, as by a 
tumor, the muscular coats of the intestine above the constriction 
hypertrophy. Compensatory hypertrophy is seen, for example, 
when one kidney enlarges following the destruction by disease 
or the surgical removal of the other kidney. It has already been 
indicated that intermittent pressure may cause hypertrophy, as 
in " corns" and calluses. Irritation by abnormal chemical sub- 
stances circulating in the blood may give rise to overgrowth of 
cells, particularly in some of the infections. 

Tumors, or new-growths, are among the most important 
conditions in the human body which are amenable to surgical 
treatment. 

The formation of a tumor is due to the increased growth of 
some of the cells in that part of the body where the tumor origi- 
nates, under the action of stimuli the character and origin of 
which are unknown. Two of the cell faculties are concerned, 
their reproductive power and their power to form those inter- 
cellular substances of which all the solid parts of the body are' 
composed. We divide all tumors into two classes, known as 
benign and malignant. In the case of the benign tumors some- 
thing like the normal balance between the reproduction of cells 
and the formation of intercellular substance is preserved; in 
other words, the cells behave like the normal mature cells of the 
part. The result is that the new-growth resembles normal 



SO THE FIELD OF SURGERY 

tissue to some extent, the tumor increases slowly in size, the 
formation of intercellular substances fixes the cells in the part 
so that there is no tendency for them to infiltrate the surrounding 
tissues or for loose cells to be carried away through the lymphatics 
or blood stream to start new tumors in other parts of the body 
(metastases). Such tumors usually have sharply defined borders. 
They do not tend to recur after removal, and their presence 
does little harm. 

In the case of the malignant tumors, on the other hand, all 
the energies of the cells are devoted to the exercise of their repro- 
ductive power; the new cells show little or no tendency to the 
formation of intercellular substances or to grow to the mature 
form of the normal cells. These tumors therefore do not resemble 
any normal tissue. The cells are not fixed, and tend to infiltrate 
the surrounding tissues and to be carried to distant parts of the 
body, to start new tumors there. They invariably cause the death 
of the patient, usually within a time varying from a few months 
to two or three years. There are two types of malignant tumors 
— one (sarcoma) in which the connective-tissue cells are the ones 
concerned, and one (carcinoma or cancer) in which the epithelial 
cells, such as form the skin and secreting glands, are involved. 
The only hope of cure lies in early and complete removal. 

2. Destructive Tissue Changes. — Atrophy is the opposite of 
hypertrophy, a wasting away of cells or tissues. Atrophy occurs 
as a normal adaptive change in involution of the uterus following 
parturition. Just as cells increase in size as a result of active 
exercise of their functions, so as a result of disuse they shrink 
away. A limb fixed in a plaster cast rapidly diminishes in size 
from wasting of the muscles, and the same is true of muscles 
paralyzed by section of a motor nerve. Atrophy resulting from 
pressure has been mentioned. A diminished supply of nourish- 
ment is a cause of atrophy, both local and general, as seen in 
starvation, and so also is malnutrition due to the inability to 
utilize food material properly, as in many wasting diseases. 

Necrosis means the death of cells. In the normal body many 
cells are constantly perishing when their usefulness is ended, this 
being particularly true of the cells of the blood, red and white, 
and of the epithelial cells which clothe the body surface. All of 
these are as constantly replaced by new cells. The causes of 
pathological cell death are either toxic or nutritional, i.e., by 
the action of poisons or by the deprivation of nourishment. 



SURGICAL PATHOLOGY 81 

Trauma, extreme degrees of heat and cold, and active chemicals 
such as strong acids and alkalies are direct causes of cell death. 
The toxins of infectious diseases, such as typhoid and diphtheria, 
circulating in the blood, cause necrosis of small groups of cells 
here and there in the liver and other organs; this being known as 
focal necrosis. It is found also in severe cases of septic disease. 
In local areas of septic infection more or less extensive necrosis 
of cells always occurs, large sloughs sometimes forming as in 
carbuncles. Depriving the tissues of the circulating fluids which 
normally bathe them is followed by death of the local cells within 
a few hours. The effect of continued pressure has been referred 
to as a cause of sloughing, a fact which should be borne in mind 
in applying bandages and splints. Gangrene is the death of 
large areas or whole parts of the body, such as the extremities, 
and is due either to cutting off entirely the arterial supply of 
blood or to obstructing the return of the blood through the veins, 
as by a tight bandage about a limb. Certain constitutional 
diseases, such as diabetes, and also the cutting off of the normal 
nerve supply to the part predispose to gangrene. 

3. Cell Degenerations. — Perverted nutrition of cells gives rise 
to changes known as degenerations. Albuminous materials 
(proteids); carbohydrates (starches and sugars); fats; certain 
salts and water are the materials entering into cell nutrition. 
The degenerative changes connected with each of these can only 
be briefly mentioned here. Many of them are named from a 
fancied resemblance to familiar substances. Thus among the 
degenerations concerned with the proteid elements of nutrition 
we have waxy or amyloid (starch-like) degenerations; hyaline 
(glass-like)-; mucoid (mucus-like); caseous (cheese-like); and 
colloid (gum-like) degenerations. Fatty degeneration, with 
deposit of minute fat globules in the cell body, occurs associated 
with damaged cell activity in many conditions. Carbohydrates 
taken with the food are stored in the body, for use in the produc- 
tion of energy, in the form of glycogen, called animal starch, and 
degenerative changes in certain cells are associated with loss of 
balance in the utilization of this material. Excessive deposits 
of lime and other salts in cell bodies and intercellular substances 
constitute what is known as calcareous degeneration. Akin to 
this perhaps is the deposit of the same materials in ducts and 
passages of the body, forming so-called calculi or stones in various 
organs, the urinary bladder, the gall-bladder, and the kidney. 
6 



82 THE FIELD OF SURGERY 

VI DISTURBANCES OF GENERAL FUNCTION 

As a result of these pathological changes in the functional, 
nutritional and formative activities of the body-cells there neces- 
sarily follow far-reaching changes in the general function of the 
body as a whole. All the great systemic divisions of the body are 
involved in varying degrees, the digestive, vascular, respiratory', 
glandular, muscular and nervous systems. These disturbances, 
arranging themselves into various groups or complexes, according 
to the nature of their origin, constitute the symptoms of disease, 
and the study of these together with the local changes which 
accompany them is what is known as clinical (bedside) medicine 
and surgery. 



CHAPTER V 
SURGICAL AND GYNECOLOGICAL NOMENCLATURE 

It is probable that no branch of her studies offers more 
constant and troublesome confusion to the student nurse than 
do the accumulation and proper comprehension of her profes- 
sional vocabulary. And, the medical nomenclature being de- 
rived from single and combined Greek and Latin words, this 
statement is particularly applicable to those who have not 
included a groundwork in the " dead languages " as part of their 
preliminary education. 

It will be the effort, in this chapter, to present the methods 
of derivation and construction in such a light that the student 
will quickly comprehend their application; will readily assimilate 
the more usual forms; and will (it is hoped) be so stimulated in 
her interest in this line of work that she will feel as lost without 
her dictionary as without her thermometer or hypodermic 
syringe. In other words, the object will be not to supplant the 
dictionary, but to so supplement it that its use will be a matter 
of pleasant investigation rather than of tedious memorizing. 

It would, of course, be far beyond the possibilities of a single 
chapter to even approximately supply the vocabulary contained 
in even the smallest of medical dictionaries. When, however, 
once a comparatively small list of root-words, prefixes and suffixes 
has been mastered, their methods of combination understood, 
and the resulting words (broad in meaning, but simple and regular 
in construction) observed, the nurse will be in a position to 
build up most of the routine words for herself — or at least to 
" unbuild " those with which she comes in contact into their 
easily recognizable component parts. 

General Derivation. — It may be generally accepted that all 
strictly medical words are either Latin, Greek, or a combination 
of the two. The facts that the earliest traditions of medicine, 
as a science, are founded in Greece and that, at a later day, 
Latin was the universal language of educated and scientific 
people, easily explain this great preponderance of terms from 
the " dead languages." 

Method of Construction. — The entire medical vocabulary 
may, broadly speaking, be considered as composed of root- 

83 



84 



THE FIELD OF SURGERY 



words — either alone or in combination with prefixes or suffixes, 
or both. The root-word may generally be considered as describing 
some definite object, as (perhaps) one of the organs of the body. 
The prefix usually describes some variation from the normal 
or defines the relation of the root-word to its environment or of 
another object to the root-word. The suffix generally describes 
some condition of, or act performed upon, the root-word. 

Root=words. — The medical vocabulary being, as already 
indicated, derived from both Greek and Latin, it is not surprising 
that we frequently find two (and even three) words meaning 
the same thing. In such cases, we inay have the common name, 
the Greek scientific name and the Latin scientific name, all in 
frequent, though not necessarily interchangeable, use. In these 
cases it will, general^, be found that either the English or the 
Latin word is used in speaking directly, by name, of the object 
and the Greek root-word in those compound words that are so 
common throughout the medical vocabulary. For instance, we 
have the English word, womb, the Latin word, uterus, and the 
Greek words, hystera and metra, referring to the same organ. 
The English word is the one in common, or vernacular, usage; 
the Latin is the one in regular, unmodified medical usage; and 
one or other of the Greek roots is regularly found in the compound 
forms. Occasionally but one root-word is in use; in other cases, 
they are both present, but identical; and, less frequently, they 
are present, different and used interchangeably. In the last 
case, however, it is generally true that the Greek root would be 
preferabry and more correct^ used. In the present listing of 
those root-words, a classification by systems will be made and, 
where both Latin and Greek roots are used, in the forming of 
compound words, both will be given. 



Respiratory System: 






Nose 


L. naso- 


G. rhino- 


Tonsil 


L. tonsillo- 


G. amygdalo- 


Larynx 




G. larj-ngo- 


Trachea 




G. tracheo- 


Bronchus 




G. broncho- 


Lung 


L. pulmo 


G. pneumo- 


Digestive System : 






Mouth 




G. stomato- 


Pharynx 




G. pharyngo- 


(Esophagus 




G esophago- 


Stomach 




G. gastro- 


liver 




G. hepato- 



SURGICAL AND GYNECOLOGICAL NOMENCLATURE 85 



Gall-bladder 




G. cholecysto- 


Bile-duct 




G. choledocho- 


Pancreas 




G. pancreato- 


Intestines 




G. entero- 


Duodenum 


L. duodeno- 




Jejunum 


L. jejuno- 




Ileum 


L. ileo- 




Caecum 


L. caeco- 


G. typhlo- 


Appendix 


L. appendico- 




Colon 




G. colo- 


Rectum 


L. recto- 




Anus 


L. ano- 


G. procto- 


Urinary System: 






Urethra 




G. urethro- 


Bladder 




G. cysto- 


Ureter 




G. uretero- 


Kidney 


L. reni or reno- 


G. nephro- 


Pelvis of kidney 




G. pyelo- 


Female Genital System: 






Vulva 


L. vulvo- 




Perineum 




G. perineo- 


Labium 


L. labio- 




Vagina 


L. vagino- 


G. colpo- 


Cervix 


L. cervico- 


G. trachelo- 


Womb 


L. utero- 


/-, / hystero- 
' \ metro- 






Fallopian tube 


L. tubo- 


G. salpingo- 


Ovary 


L. ovario- 


G. oophoro- 


Regions of Body: 






Head 




G. cephalo- 


Neck 


L. cervico 


G. trachelo- 


Chest 




G. thoraco- 


Abdomen 


L. abdomino- 


G. celio- 


Tissues : 






Skin 




G. dermato- 


Fat 




G. lipo- 


Muscle 


L, musculo- 


G. myo- 


Bone 




G. osteo- 


Marrow 




G. myelo- 


Cartilage 




G. chondro- 



In the preceding list, the actual word has not been given, 
but the root form (as found under altered conditions in our 
compound words) is presented. Such a list is, necessarily, full 
of omissions, but should (taken in connection with those follow- 
ing) give a fairly comprehensive working idea of those names 
used in the diagnoses of surgical diseases and the operations for 
their relief. 



86 THE FIELD OF SURGERY 

Prefixes. — As has already been stated, the prefix usually 
describes some variation from the normal or defines the relation 
of the root-word to its environment, or of another object to the 
root-word. The succeeding list gives some of the prefixes in 
most common use — and. at the end oi the suffixes, will be found 
some examples of the utilization of prefixes, root-words and 
suffixes in the formation of compound words. It will be noticed 
that these prefixes are taken from both Greek and Latin. 

A- or An- means .: r ' :<:•: or ':;•:, 

Ab- means ; 

Ad- means to. 

Ante- means before. 

Anti- means against. 

Circuin- means aro 

Con- means together. 

Contra- means age. i 

De- means down or from or em 

Dia- means through. 

Dis- means apart. 

Dys- means difficult or painful. 

E- means without. 

Ec- means out. 

Ecto- means without or on the outside of. 

En- means in. 

Endo- means within. 

Epi- means upon. 

Eu- means well. 

Ex- means out or away from. 

Exc- means outside. 

Extra- means outside of or beyond. 

Hyper- means above or beyond. 

Hypo- means deficiency of or under. 

In- means in. into or not. 

Inter- means bet 

Infra- means beneath. 

Intra- means within. 

Para- means beside. 

Peri- means around. 

Poly- means many. 

Post- means after or behind. 

Pre- means before. 

Re- means again. 

Retro- means backward. 

Sub- means below or under. 

Super- means above. 

Supra- means abo\ 

In the list above, there are necessarily a number of prefixes 
which are less common than the others. In the succeeding list 
of suffixes, however, it is fairly safe to say that the very large 
majority (if not all) will be constantly encountered in terms 



SURGICAL AND GYNECOLOGICAL NOMENCLATURE 87 

used in the wards and in the operating-room, particularly the 
latter. Many medical and the greater part of surgical diagnoses 
and nearly all surgical operations, when described in medical 
terms, will include one or another of these suffixes. 

Suffixes: 

-algia means -pain in. 

-cele means hernia of. 

-cleisis means closure of. 

-dynia means pain in. 

-ectasis means dilatation of. 

-ectomy means excision of. 

-ectopy .means displacement of. 

-itis means inflammation of. 

-lith means stone. 

-oma means tumor. 

-osis means disease. 

-pathy means disease. 

-pexy means fixation of. 

-ptosis means falling of. 

-rrhaphy means sewing of. 

-rrhagia means bursting out from. 

-rrhea means flowing. 

-rrhexis means rupture of. 

-scopy .means viewing of. 

-stomy means making a mouth in or between. 

-spasm means spasm of. 

-tomy means cutting of. 

-trismus means spasm of. 

Having attempted to give sufficiently full lists of root-words, 
prefixes and suffixes to at least give the nurse a fair groundwork 
in building up a surgical vocabulary — a number of examples of 
these built-up words will be taken and separated into their 
component parts, to give an idea of the application of this sort 
of learning in practical work. 

First, let us take that best known of all surgical complaints — 
appendicitis. We have here a combination of the root-word 
"appendico" and the suffix "-itis." Reference to the lists will show 
that this combination means " inflammation of the appendix." 

As a second example, let us take another of the more common 
of the disease conditions (this time gynaecological), " endo- 
metritis." Here we find prefix, root-word, and suffix. Reference 
to the lists gives us the meanings: " endo-," within; " metro-" 
the womb; "-itis," inflammation of. Hence, we have " endo- 
metritis," or an inflammation of the lining of the womb. 

Similarly, we have those compound words that represent 
operative procedures. Gastrostomy means making a mouth (or 



88 THE FIELD OF SURGERY 

opening) in the stomach. Perineorrhaphy means sewing of the 
perineum. Cystoscopy means viewing of the bladder. 

Abbreviations. — A discussion of the subject of medical and 
surgical nomenclature should not entirely omit brief reference 
to those abbreviations commonly used in hospital work and pri- 
vate practice, when writing orders for the nurse's direction. 
Accordingly, a short list of the more common of these abbrevia- 
tions, with their meanings, is appended. 

aa. from ana, meaning of each. 

A.c from ante cibum, meaning before meals. 

Ad lib from ad libitum, meaning as desired. 

Aq from aqua, meaning water. 

B.i.d from bis in die. meaning twice daily. 

e from cum. meaning with. 

c.c. or c.cm from cubic centimetre, a unit of volume. 

cm from centimetre, a linear unit. 

G. or Gm from gramme or gram, a unit of weight. 

gtt from gutta, meaning a drop. 

H from hora, meaning hour. 

P.c from post cibum. meaning after meals. 

P.r.n from pro re nata. meaning according to circumstances. 

Q from quaque. meaning every. 

Q.S from quantum sufficit. meaning a sufficient quantity. 

S.o.s from si opus sit. meaning if necessary. 

ss from semis, meaning half. 

T.i.d from ter in die, meaning thrice daily 



CHAPTER VI 
THE SURGICAL FIELD 

The distinction between medicine and surgery rests entirely 
upon the methods of treatment employed. The word surgeon 
is derived from two Greek words meaning hand and work. A 
surgeon, therefore, is one who works with his hands, and surgery 
is that branch of the science of medicine in which the remedial 
measures that are required consist of manual or operative pro- 
cedures. The diseases and affections with which the surgeon has 
to deal constitute the field of surgery and may be briefly sum- 
marized as follows: 

I. OUTLINE OF THE SURGICAL FIELD 

1. Affections Which Are not Caused by Disease. — (1) Ana- 
tomical Defects. — These may be congenital, as in the case of 
hare-lip and cleft palate, or acquired after birth, as in the case of 
certain forms of hernia, and the results of burns or other injuries. 
The operative means employed in their treatment are spoken 
of as plastic or reparative operations. 

(2) Mechanical Derangements. — Conspicuous examples of 
these are the forms of intestinal obstruction produced by torsion 
(volvulus) or telescoping (intussusception) of the intestinal 
tube, conditions which become rapidly fatal if not given prompt 
relief. Displacement of various abdominal organs (floating 
kidney, enteroptosis) gives rise to many distressing chronic 
symptoms. Mechanical distention of veins occurs in various 
parts of the body (varicocele, varicose veins of the leg). Affec- 
tions which mechanically interfere with the various functions 
of the body may be the result of injury and also sometimes of 
disease. 

(3) Foreign Bodies. — Various articles held in the mouth and 
accidentally swallowed may become lodged in the oesophagus, 
stomach, or air-passages. Foreign bodies, such as bullets em- 
bedded in the tissues, frequently require removal. 

(4) Trauma. — This means any injury of the tissues of the 
body produced by violence. In this class are included wounds, 
open or subcutaneous, contusions and crushing injuries, burns, 



90 THE FIELD OF SURGERY 

fractures of bones, dislocations of joints, and any " internal " 
injuries resulting from violent means. Surgical treatment is 
called for in cases suffering from trauma always at the time of 
injury and sometimes later, after the injury has healed. Thus 
accidental wounds, like surgical wounds, must be properly 
" closed," so as to bring divided nerves, muscles, skin, and other 
tissues into normal position with relation to each other; fractures 
must be " set " and retained in place by splints or other me 
dislocations must be "reduced'"; bleeding from divided arteries 
or veins must be controlled; appropriate steps must be taken to 
prevent infection of the injured tissues; and special methods of 
treatment appropriate to certain injuries too numerous to be 
mentioned here must be employed. After an injury has healed, 
structural defects or other conditions resulting from it may 
bring the patient under the hands of the surgeon for operative 
treatment. In the field of gynaecology the conditions resulting 
from trauma are for the most part those which are incident to 
child-birth, such as lacerations of the cervix and perineum, 
vesicovaginal fistula, and so on. These, conditions frequentfy 
call for operative repair at a later period. The emergency meas- 
ures which the nurse may be called upon to employ in the immedi- 
ate treatment of injuries will be considered in a separate chapter. 
2. Diseases and Affections Arising from Disease. — (1) The 
Infections. — The greater number of diseased conditions caused 
by the entrance of single-celled organisms into the body come 
under the care of the physician. The principal organisms con- 
cerned in what may be called the surgical infections have already 
been described. The bacteria of sepsis, which have been enumer- 
ated in speaking of the infection of wounds, are often encountered 
as disease-producing invaders in the body when no visible wound 
is present, having found a portal of entrance through some minute 
break in the surface either of the skin or of the mucous mem- 
brane. When septic bacteria are growing in a number of small 
areas scattered throughout the body, or when the locality of 
their attack cannot be determined, surgical treatment is not 
available and the disease must be considered as belonging to the 
province of the physician. Cases of septic infection become 
surgical when the disease is localized in some definite area in 
the body, since in that case the proper treatment consists in the 
establishment of drainage; that is, the opening up by operative 
means of a way of escape from the body for the poisonous products 



THE SURGICAL FIELD 91 

produced by the growing bacteria, In many cases also portions 
of tissue or even entire organs too extensively diseased to be 
capable of recovery have to be removed. Septic infections of this 
character are very common and of great variety. They include 
superficial lesions, such as boils, and carbuncles, and ulcers, 
abscesses in almost ' every part of the body, infections of the 
serous membranes lining the great body cavities, such as the 
pleura and peritoneum. The joints and even the solid bones may 
be the seats of septic infection. The organism of Neisser (gono- 
coccus) plays the leading role in the pelvic infections in women 
which are responsible for a large proportion of the operative work 
that the gynaecologist is called upon to perform. Infective lesions 
beginning in the mucous membrane of the intestine, and resulting 
in perforation of the intestinal wall, allow the escape of highly 
infective material into the peritoneal cavity, and give rise to 
general or localized peritonitis, requiring prompt operative inter- 
ference for its relief. The vermiform appendix is by far the most 
common seat of such perforative lesions. The infection here is 
necessarily of a mixed character, owing to the varied bacterial 
content of the material poured out from the intestine. The colon 
bacillus, the staphylococcus, and the streptococcus are the organ- 
isms almost invariably found. 

The tubercle bacillus is the cause of a great variety of condi- 
tions requiring surgical treatment. This organism attacks almost 
every tissue and organ in the body. Tuberculosis of the lymphatic 
glands, of the bones and joints, and of the kidney and bladder 
are the most common forms of this disease which come under 
the care of the surgeon. 

(2) New-growths. — -Nearly every tissue in the body may 
become the seat of an abnormal enlargement known as a tumor, 
consisting of an excessive growth of tissue more or less resembling 
the normal, usually with well-defined boundaries, but tending to 
progressive increase in size and sometimes to the formation of 
similar tumors in other parts of the body at a distance, through 
the proliferation of cells carried from the original tumor through 
the blood or the lymphatic circulation. Very little is known about 
the causation of these new-growths. The only successful treat- 
ment of them consists in their removal by operative means. 

(3) Other organic diseases and affections arising from them are 
amenable to surgical treatment in numerous instances too varied 
to be briefly summarized. A few examples must suffice. The 



92 THE FIELD OF SURGERY 

harmful effects of an overactive or perverted gland secretion 
may call for the partial removal of the offending organ, as in the 
case of exophthalmic goitre. Obliteration of smaller arteries 
from chronic disease (arteriosclerosis, diabetes) may lead to 
gangrene of the extremities, requiring amputation. Evacuation 
of fluid accumulated in various body cavities as a result of disease 
is a surgical measure often called for. Concretions and calculi 
are formed by the deposit of calcareous salts in various ducts 
and passages of the body. Gall-stones and stones in the bladder, 
ureter or kidney are the most common examples of this class. 
Such bodies frequently require operative removal. 

(4) Functional Diseases.- — Examples of purely functional 
disease, either medical or surgical, are very few. Neuralgia is 
the name of a condition in which there is usually only a single 
symptom present, namely pain, and often no discoverable organic 
tissue change. Surgical treatment is sometimes resorted to when 
other means of relief have failed. 

II. SURGICAL SPECL1LISM 

The field of surgical knowledge is so- wide that it is impossible 
for a single mind to master the innumerable details necessary 
to be known in order to do efficient work in the diagnosis and 
treatment of surgical conditions in all parts of the body. The 
result is a division of the surgical field into a number of depart- 
ments or specialties, so that by confining his attention exclusively 
to one of these a surgeon may attain a higher degree of efficiency 
in his work. It is the difficulties of diagnosis rather than of 
treatment that make specialism necessary. A large experience, 
that is, the opportunity to observe and study many cases, and 
a wide scientific knowledge are indispensable in making a correct 
diagnosis in many cases. Skill in the use of the many and often 
highty complex instruments of diagnosis that have been devised 
for use in the various special fields can be acquired only by 
constant practice. Contrary to the popular idea, operative 
skill is the least important and most easily acquired part of the 
equipment of a competent surgeon. The recognized surgical 
specialties we may take to be those which are usually assigned 
to separate departments in hospital work. 

1. Ophthalmology. — Treatment of diseases of the eye is 
largely surgical. It is a wide field in itself, giving scope for the 
highest ability and skill. 



THE SURGICAL FIELD 93 

2. Otology, or surgery of the ear, is a narrower field frequently 
combined with surgery of the throat and nose or of the eye. 

3. Surgery of the throat and nose (laryngology, rhinology) is 
an important specialty in which many practitioners are engaged 
on account of the great frequency of diseases and affections in 
this region. 

4. Gynaecology deals with the diseases and affections of the 
female genito-urinary organs. It is a separate department in 
most hospital organizations, and is a specialty of the greatest 
interest and importance for the surgical nurse. 

5. Genito=urinary surgery is the name applied to that specialty 
which deals with the diseases and affections of the kidney, 
bladder, and genital organs in the male. The setting aside of 
this portion of the surgical field as a special department is made 
particularly necessary by the high degree of skill required in the 
use of a wonderful instrument of diagnosis, the cystoscope, by 
means of which the interior of the bladder can be inspected and 
surgical conditions of the kidney directly demonstrated. 

6. Orthopaedic surgery deals with the treatment and the 
prevention of deformities, particularly in children, either con- 
genital or acquired, the latter most commonly as the result of 
trauma, tuberculous disease of the bones and joints, or infantile 
paralysis. The treatment of these conditions, while partly 
operative, consists largely in the fitting of proper braces and 
supports, and also in the training of particular groups of muscles 
by special exercises — forms of treatment which must be carried 
out over long periods of time and which require a high degree of 
patience, knowledge, and skill in their application. 

7. Surgery of the Nervous System. — The brain and spinal 
cord are subject to all the forms of surgical disease and affection 
that have been enumerated, especially perhaps to trauma and to 
affections resulting from pressure due to the presence of tumors 
or new-growths. A few practitioners, exceptionally well qualified 
by reason of experience and ability, usually resident in large 
centres of population, have specialized in this department. It 
is perhaps the most difficult of all fields, but the cases are not 
numerous enough to support many specialists, and in areas 
where these are not available such conditions come Under the 
care of the general surgeon. 

8. General sur'gery includes all that remains of the wide 
domain of surgery outside of the narrower fields included in the 



94 THE FIELD OF SURGERY 

special departments. There are, of course, many border-line 
cases. A case may, because of the nature of the disease or affec- 
tion or of its complications, come within the province of more 
than one special department. In operations within the abdomen 
the work of the general surgeon and that of the gynaecologist 
frequently overlap. Both general surgeons and orthopaedists treat 
fractures and infections involving bones and joints; and there are 
a number of other classes of operations which the general surgeon 
has not yet wholly resigned to the special department to which 
a strict classification might assign them. 

III. OPERATIVE SURGERY 

1. Nomenclature. — A major operation is one that is extensive, 
involving the deeper parts of the body. A minor operation is 
one that involves only the skin or mucous membrane and the 
superficial tissues. An operation is spoken of as capital when it 
involves danger to life; radical or complete when it is intended to 
cure a disease or affection; palliative when it is done to relieve 
some distressing symptom without expectation of cure. An 
exploratory operation is one in which an incision is made to 
bring into view some deeper part of the body, most frequently 
the abdomen, for purposes of diagnosis. A plastic operation is 
one where flaps of skin or mucous membrane are moved to a new 
position to cover a defect. Incision is a simple cut. Excision is 
cutting out, to remove a tumor or portion of tissue or organ. 
Resection is cutting from between, as the removal of a joint, or 
a portion of a long bone, or of a nerve, or of the intestinal tube. 
Anastomosis is the establishment of a communication between 
portions of a hollow organ. The term is applied to operations 
of this character on the stomach and intestines and on arteries 
and veins. Many special operations are known by the name of 
the surgeon who first performed them. The meanings of many 
compound words, including names of operations, have been ex- 
plained in the chapter on nomenclature. A two-stage operation 
is one in which at a certain point the operation is stopped, the 
wound closed and the patient sent back to the ward. The opera- 
tion is then completed at another time some days later. There 
may be two reasons for doing this. One is that completion of 
the operation at a single stage would add materially to the opera- 
tive risk. The other is that in certain cases it is desirable for the 
healing process to have time to make a certain amount of progress 



THE SURGICAL FIELD 95 

between the first steps and the later steps of the operation. This 
intervention of the healing process between two stages of an opera- 
tion may be required, for example, to close off the pleural or the 
peritoneal cavity before opening an abscess or a loop of intestine 
which has been drawn out to form an artificial anus. It may also 
be an advantage or a necessity in certain plastic operations. 

2. Operative Hazards. — Operative surgery has one distin- 
guishing characteristic, of the greatest gravity and importance, 
which it shares with no other method employed in the treatment 
of disease. It is attended in many cases with danger to the life 
of the patient. In the treatment of medical cases an overdose 
of a drug may kill, or an error in treatment may hasten the inevi- 
table end or permit a fatal issue that could have been avoided; 
but almost without exception every properly used therapeutic 
measure, other than surgical, is free from direct hazard to life 
or health. This feature of the work of the surgeon has undergone 
a great and wonderful change for the better within the last fifty 
years. Before the days of antiseptic and aseptic surgery, the 
operative risks were appalling. Operations that are now done 
daily with scarcely a thought of danger were then attended with 
a death rate of thirty to fifty per cent, or more. Many opera- 
tions now regarded as very moderate risks could not be under- 
taken at all. The elimination of septic infection in surgical 
wounds, which began with the work of Lister, has thus wrought 
a truly revolutionary change with respect to operative hazards, 
and other important advances have contributed largely to the 
same end. The time will never come when all surgical operations 
will be free from danger, but under modern conditions, in the hands 
of competent surgeons and properly trained nurses, we may 
roughly group all operations into three classes with respect to 
operative risks: (1) the largest class includes all minor and many 
major operations, numbering possibly three-fifths of all cases, 
in which the danger is negligible, being scarcely more than that 
from the ordinary accidents of daily life; (2) a smaller but numer- 
ous group of cases in which there is a risk varying from very 
moderate to moderately grave; (3) a small group of cases involv- 
ing very grave risk. 

The three primary operative risks are shock, hemorrhage, 
and infection, including sepsis and pneumonia. All of these are 
preventable in most cases with a very high degree of certainty. 
There are a number of other operative dangers that are under 



96 THE FIELD OF SURGERY 

perfect control and also very much less frequent, and one 
or two. fortunately rare, against which we have as yet practically 
no safeguards. The character of the various dangers and the 
methods of forestalling and combating them will be considered 
in a later chapter. As regards time, the critical period following 
an operation may be said to last from three to five days, after 
which, if all has gone well, the patient may usually be considered 
out of danger. 

3. Mortality [as applied to operative surgery; means the 
death rate expressed in percentage; that is, the number of deaths 
in every hundred operations (of the particular kind in question ) 
that have been recorded. Mortality is usually estimated for 
each particular operation without regard to other factors which 
influence it, since these are very variable and difficult to determine 
accurately. The direct causes of death are numerous, including 
the immediate effect of the operation itself and all the complica- 
tions that may arise afterward. The predisposing causes are the 
factors which chiefly affect mortality, and these may be grouped 
under four heads: (1) The extent and severity of the operation. 
Eor example, the mortality of amputations at the hip-joint is 
much greater than that of amputations at the knee. (2) The 
character of the operation without regard to its severity. For 
example, the mortality of ligation of the common carotid artery, 
a comparatively simple operation in itself, is very high because 
of the shutting off of the blood supply from the brain. (3) The 
resisting power of the patient, a factor which must always be 
carefully estimated beforehand by the surgeon. (4) The thor- 
oughness and conscientiousness with which the details of asepsis 
and other parts of the technic are carried out. 

4. Morbidity in relation to operative cases) means the period 
of illness following an operation. It is ordinarily measured by 
its duration. There is an unavoidable morbidity following every 
operation. A patient operated upon, often with unimpaired 
general health beforehand, then passes through what may be 
regarded as an acute illness, and for practical purposes this may 
be said to last as long as he is disabled from his ordinary occupa- 
tion. For uncomplicated abdominal operations the minimum 
duration of morbidity may be set at about two weeks, for slighter 
operations it will be considerably less, and in the severer cases 
may extend to a month or more. When complications arise 
morbidity may be prolonged to an indefinite extent. Morbidity 



THE SURGICAL FIELD 97 

is, of course, subject to variation in severity or intensity as well 
as in duration. 

5. The Surgical Obligation. — The operative hazard imposes 
upon the surgeon and upon the surgical nurse a unique and pecu- 
liarly binding obligation. In no other occupation is a serious 
risk of life involved to the recipient of a personal service. The 
patient, therefore, is compelled to repose a great trust in those 
into whose hands he commits himself, and the possibility of 
failing him in any avoidable way is not a matter to be lightly 
regarded. For a patient, in good general health and undergoing 
an operation of slight or moderately grave danger, to die as a 
direct result of the operation is a disaster of such magnitude 
that no labor or painstaking care is too great to be exacted of 
those responsible for the work. In the graver cases the result 
may turn on small things. A failure to estimate properly some 
factor in the patient's condition, a slip in the technic, a failure 
through carelessness to notice in time premonitory symptoms of a 
coming complication, delayed or perfunctory carrying out of an 
important remedial measure, may determine a fatal issue. In 
the majority of operations the risks are small, but they are in- 
creased in proportion whenever any failure occurs in applying 
all available means for safeguarding the patient. The responsi- 
bility for this rests principally and primarily upon the surgeon, 
but the surgical nurse shares it with him in large measure in 
certain aspects of the work, particularly in the operating-room 
technic and in the care of the patient after operation. 



PART III— MINOR TECHNIC IN 
SURGICAL NURSING 



CHAPTER VII 

POSTURES 

In the various procedures of surgery and gynaecology, whether 
for purposes of examination, treatment or operation, there are 
numerous variations of the posture of the patient that are re- 
sorted to for the purpose of simplifying the anticipated procedure. 
The greater part of these postures are really variations of the 
horizontal recumbent position, and will be considered as such 
in their regular order as decided by the degree of variation from 
the original position. 

1. Horizontal Recumbent Position (Fig. 36). — This position, 
as the name would imply, is that normally taken by the patient 
when reclining flat upon the back. The legs are together and 
the arms may be in any of three positions, depending upon the 
object in view and, partly, upon the preference of the physician. 
For purposes of abdominal operation upon the lower abdomen 
or of abdominal examination, the arms may be placed either 
alongside the body, across the chest, or above the head. If the 
operation is to be upon the upper abdomen, the position of the 
arms across the chest would, naturally, be undesirable, as they 
might interfere with the operator. In this case, either of the 
other arrangements would be equally satisfactory. 

2. Trendelenburg Position (Fig. 37). — This position is identi- 
cal with the horizontal recumbent so far as the immediate relation 
of the patient to the top of the table is concerned. The difference 
in the two positions is based upon the changing of the level of 
the table top. By a mechanical adjustment upon the table, the 
patient's head is lowered so that the top of the table takes an 
angle of anywhere from 10 degrees to 45 degrees with the horizon. 
The object of this position is the gravitation of the intestines 
out of the pelvis into the upper abdomen. For the proper use 
of this position, it is necessary to have a table with shoulder 
supports and a sectional arrangement by which the lower end 
may be depressed so that the legs are flexed on the thighs. This 
combination gives proper support to the patient so as to prevent 
slipping off the table in the higher elevations. The position is 
generally taken just after the abdomen is opened. 

101 



102 



MINOR TECHNIC IN SURGICAL NURSING 



3. The Reversed Trendelenburg Position. — As the name 
would signify, this position is identical with the last mentioned, 
except for the reversal of the patient's position. Here the feet, 
instead of the head, are lowered. Its application is not a very 



A 



Fig. 36. — Horizontal recumbent position. 



wide one, — resort being had to it only in those infectious cases 
where it is vital to take every precaution to prevent already 
existent pus from gravitating into the upper abdomen. Where 




Fig. 37. — Trendelenburg position. 



used, this position is arranged at the very outset, — the patient 
being put on the table in this position. The patient is generally 
retained in position by adhesive plaster strapping, by towels or 
straps passed around the thighs and fastened to the table, and by 



POSTURES 103 

the use of a board supported on the shoulder rests, — used in this 
position as a foot rest. 

4. Dorsal Position (Fig. 38). — This position, above the hips, 
is identical with the horizontal recumbent position. Here, how- 
ever, the thighs are flexed upon the body and the legs upon the 
thighs, — the heels resting in stirrups that are adjusted to arms 
attached to the table. The flexion of both thighs and legs is 
moderate, as is the separation of the thighs. This position is 
particularly adapted to vaginal inspection, or the digital and 
bimanual examination. 



§ 

i 

Fig. 38. — Dorsal position. 

5. Dorsal Elevated Position. — This position differs from the 
simple dorsal position only in the elevation of the shoulders of 
the patient, by placing enough pillows or pads under them to 
attain the desired elevation. The advantage of this position 
over the former is in those cases where it is necessary to flex the 
body in order to relax the abdominal muscles for proper bimanual 
examination of the pelvic organs. 

6. Dorsosacral (Lithotomy) Position (Fig. 39). — The dorso- 
sacral (lithotomy) position differs from the dorsal only in the 
matter of degree and the method used in its attainment. Instead 
of a slight flexing of the thighs upon the abdomen and legs upon 
the thighs, the flexion is pronounced, the angles formed between 



104 



MINOR TECHNIC IN SURGICAL NURSING 



the respective parts being 90 degrees or less. Instead of the 
simple stirrup foot rest, an upright rod with foot sling is attached 
to each side of the table and the legs flexed sharply back, — -the 
foot passing to the outer side of the rod and through the sling. 




Fig. 39. — Dorsosacral (lithotomy) position. 



This position is used for perineal and vaginal operations and for 
operations upon the rectum. It is also used for the cystoscopic 
examination of the bladder with the electric cystoscope. 

7. Elevated Dorsosacral Position. — The difference between 
the simple and elevated dorsosacral positions is diametrically 



POSTURES 105 

opposite to that between the simple and elevated dorsal positions. 
Here it is the hips that are elevated by pads or the Trendelenburg 
attachment. The elevated position is sometimes preferred for 
the sake of convenience and is also used by some physicians for 
bladder examination with the Kelly cystoscope. 

8. Right (or Left) Lateral=Prone Position (Fig. 40).— This 
position is also known as the Sims position and is practically 
identical with the kidney position. As a gynaecological posture, 
it is used for inspection of the vulva, vagina and cervix, or for 
local treatment of the same parts. 

In this position, the patient is placed on her side at the edge 
of the table, — with her lower arm behind her and her upper arm in 
front and flexed naturally across her chest. Both knees are drawn 



■ '■i'l 



\ 



Fig. 40. — Right lateral-prone position. 

up toward the body, — the upper higher than the lower and resting 
on the table. The patient is draped with a sheet so that the body 
and legs are covered and only the parts to be examined exposed. 

9. Knee=chest (Genu=pectoral) Position (Fig. 41). — This posi- 
tion is the one of choice for the examination of the bladder, 
vagina or rectum by a tubular speculum aided by air disten- 
tion. It is most commonly used in connection with the Kelly 
cystoscope. 

The patient kneels upon the table, with her feet extending 
over the edge. The knees are slightly separated. Her face is 
turned to one side and rested upon a pillow provided for the 
purpose, — the upper chest resting upon the table as near as pos- 
sible to the knees. The points to be chiefly observed in the proper 
attaining of this position are: (1) the maintaining of a vertical 



106 MINOR TECHXIC IN SURGICAL NURSING 

position of the thighs; and (2) the resting of the chest upon the 
table. The patient should be draped so as to expose the vulva 
alone. 

10. Erect Position. — This position is particularly adapted to 
vaginal examination for the purpose of determining the presence 
or degree of prolapse of the uterus. The patient may take either 
of two positions: (1) with the foot resting upon the round of a 




^ 




Fig, 41. — Genu-pectoral (knee-chest) position. 

chair and the corresponding hand upon the chair's back, — the 
other hand resting upon her hip; or (2) with feet separated and 
both hands resting upon her hips. 

VARIATIONS FROM THE USUAL ARRANGEMENT AND EQUIP- 
MENT IN OPERATIONS 

While the foregoing descriptions may be accepted as the rule 
and followed in those cases where circumstances and the equip- 
ment permit, there are necessarily times when the usual wealth 
of supplies found in the well-regulated operating room will be 
lacking and when the best must be done with the materials at 
hand. This is particularly the case with operations in private 
houses, where the operating table may be supplied by that 
ordinarily used in the kitchen and the other necessities by the 
surgeon or the household linen room. In discussing these cases, 
but brief reference will be made to those supplies that may be 



POSTURES 107 

brought by the surgeon and more full description of those pro- 
cedures by which the nurse may be required to overcome the 
natural difficulties of the situation as it bears upon that branch 
of the subject under discussion. 

1. The Trendelenburg Position. — In abdominal gynaecologi- 
cal operations in private houses, it is the duty of the surgeon to 
provide the necessary apparatus for obtaining the Trendelenburg 
position (Fig. 37), should he desire to use it. There are frames 
specially designed for this purpose and made by the instrument 
makers in a portable form. A rough substitute may, however, 
be made by reversing a straight-backed chair so that it rests 
upon the front edge of the seat and the top of the back. 

2. The Lithotomy Position. — This is a position that is used 
in most of the gynaecological operations performed in private 
houses, as it is generally minor operations that are done in these 
surroundings. Evidently, the kitchen table has no lithotomy 
posts or foot holders, nor attachments for their adjustment. 
Assuming that the surgeon has not brought his own table with 
the necessary appliances, how is the difficulty to be met? If 
properly supplied, the surgeon may meet the emergency by 
bringing adjustable lithotomy posts and foot holders or one of 
the lithotomy slings with which the market is deluged. If not, 
the nurse must meet the requirements as best she may with the 
supplies at hand. The lack is usually supplied by a large bed 
sheet, so folded and applied as to maintain the patient in the 
desired position. There are two methods in general use, either 
of which is likely to give satisfaction. In the first, a large sheet 
is folded diagonally and placed on the table with the long, folded 
edge under the patient's shoulders and the apex hanging over 
the lower end of the ta,ble. The patient is then placed in the 
lithotomy position and the long ends of the sheet that hang down 
the sides of the table are brought under the thighs, between the 
legs and up the body, being tied under the patient's neck by 
carrying one under the neck and tying to the other. A sheet 
properly adjusted in this manner will hold the patient in a very 
satisfactory lithotomy position. The second method consists in 
folding a sheet in several thicknesses lengthwise until it is only 
from eight to twelve inches wide. The sheet is then passed under 
the table and the ends brought out up over the body of the 
patient. The patient is put in the lithotomy position and the 
two ends of the sheet carried between the thighs, outward over 



108 MINOR TECHNIC IN SURGICAL NURSING 

them with sufficient force to hold the thighs well flexed in posi- 
tion and fastened securely to the part coming up over the table, — 
several safety pins serving very well for this purpose. 

3. The Knee=Chest Position. — The knee-chest position under 
an anaesthetic. It is quite true that this position is neither 
generally nor, indeed, very frequently used in conjunction with 
general anaesthesia. But, at the same time, it is true that, 
when the occasion does arise, the confusion is all the greater 
for the very infrequency of its use. There are two solutions of 
the difficulty, a plenitude of assistants to hold the patient in 
position or lithotomy posts and slings. The sling, in this case, 
should be a broad and well-padded one, as the weight of the 
patient must be sustained by resting her thighs in these. The 
patient is put in the knee-chest position, after being completely 
under the influence of the anaesthetic, and the slings placed around 
her thighs and fastened to the posts, in such a manner as to 
support her weight and maintain her in the proper position. 



CHAPTER VIII 

BANDAGING 

I. PRINCIPLES OF BANDAGING 

It is impossible, in a brief chapter, to describe in detail all 
the numerous and often complex ways of applying a bandage 
that have been devised, and it is also unnecessary, since the nurse 
will rarely if ever be called upon to apply any but the more 
simple forms. As a matter of fact, the surgeon rarely adheres 
strictly to the rules laid down, but varies his methods to suit 
the individual case. There are, however, certain fundamental 
principles in bandaging that are of the greatest importance, and 
these should be as clearly understood by the nurse as by the 
surgeon. A badly applied bandage may be a source of great 
discomfort and even of serious danger to the patient. A bandage, 
although properly applied at the time it was put on, may later 
become ineffective, or possibly injurious, because of a change in 
the condition of the part bandaged, for example, through in- 
creased or diminished swelling, or because of a change in the 
position of the part, or a disarrangement of the bandage itself, 
due to accident or other cause. When such a condition arises 
the nurse will usually have the first opportunity to recognize 
the fact, and she should be able to understand what is wrong 
so as to call the attention of the surgeon to it, either immediately 
or at his next visit, according to the circumstances of the case. 
When a surgeon has occasion to examine a bandage that has 
been applied by an inexperienced student, interne or nurse, he 
will not observe or criticise the character of the " turns " selected 
(spiral, reverse or figure-of-eight), or whether these are put on 
in the exact order or manner described and pictured in the text- 
books. What he will note particularly, on the other hand, will 
be the character, amount and distribution of the dressing or 
padding material under the bandage; the area included, whether 
too scanty or too extensive; whether the bandage is applied so 
as to have the proper grasp of the limb or other part of the body 
to which it is applied, so that it will not tend to slip ; the amount 
of tension, particularly at the edges and over bony points; and 
finally (and also of least importance), the smoothness and neat- 
ness of the overlying folds. A bandage that is the perfection 
of neatness may be hopelessly bad in the essential particulars, 

109 



110 MINOR TECHNIC IN SURGICAL NURSING 

and some of the most skilful surgeons, although the bandages 
which they apply are models of efficiency, pay little or no atten- 
tion to their external appearance. We may now give a brief 
summary of the general principles of bandaging and these will 
be included under two headings, first those which refer to the 
efficiency of the bandage, its proper application with reference 
to the purpose for which it is employed. These are of the first 
importance and should always be kept uppermost in mind. Under 
the second head will be given those points, of minor importance 
relatively, which refer to the neat appearance of the bandage. 
Principles which concern the efficiency of a bandage : 

1. An arm or leg, when a bandage includes one or more of 
its joints, should always be bandaged in the position it is to remain 
in afterwards. 

2. With a few exceptions a bandage should never be applied 
next the skin, an elastic padding usually of cotton being placed 
between the skin and the bandage. The exceptions are (a) when 
a bandage of flannel or elastic fabric is applied for pressure, (6) 
the Unna's paste bandage, (c) the bandage for a Buck's extension; 
here the padding is placed only over bony points and edges. 

3. Skin surfaces should never lie in contact. At the fold of 
the groin, at the bend of the elbow and knee, between the fingers 
or between the arm and the side, padding should be placed to 
keep skin surfaces apart. 

4. A bandage should exert even pressure everywhere. There 
should be no tight bands. 

5. When a bandage of an arm or leg is required to be put on 
with firm pressure for any reason it should extend from the base 
of the fingers or toes up, otherwise constriction of the limb will 
result with swelling below the bandage. 

6. To secure a proper grasp of the limb a bandage on an arm 
or leg should cover all the space between two joints or include 
the joint above or below in the turns of the bandage. 

Points which concern the neat appearance of the bandage : 

1. The turns of a bandage should lie flat, not with one edge 
tight and the other wrinkled. 

2. Each turn should overlie two-thirds of the preceding turn. 

3. The edges should lie in parallel lines. 

4. The points where the edges cross should lie in a straight 
line. 

These points are well illustrated in Figs. 61 and 62. 



BANDAGING 
II. FORMS AND USES OF BANDAGES 



111 



When we speak of bandages we ordinarily mean the roller 
bandage which is so extensively used in surgery; but there are 
a number of other forms which are in constant use, some of 
which will be described later in the chapter on the operating- 
room outfit. Thus we have the triangular bandage (Fig. 42), 
used as a sling for the arm and sometimes for other purposes; 
the T-bandage (Fig. 43); the four-tailed bandage (Fig. 44); the 




Fig. 42. — Triangular bandage. (Eliason's Practical Bandaging.) 

SZM 



Fig. 43.— Single T-bandage. 





-Four-tailed bandage. 



plain abdominal binder; the many-tailed bandage; the Scultetus 
(Fig. 45) ; and some special forms of bandages, such, for example, 
as those used for supporting the female breast. 

In the employment of all these forms of bandages there are 
three principal purposes that are aimed at, either singly or in 
combination. These are (1) the retention of dressing materials 
over a wound, (2) fixation of the part with the aid of splints or 
of some stiffening material impregnating the bandage itself, 
(3) the application of pressure. 



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BANDAGING 



113 



object being to make the bandage more secure and give it a 
certain amount of rigidity. Two-and-one-half and four-inch 
widths are the usual sizes. The bandages are soaked in water 
and wrung out before being applied. It will add much to the 
surgeon's good temper if the nurse will remember to pull off all 
the ravellings from the edges of the wet crinoline bandages before 
handing them to him. Crinoline is also used as the material from 
which plaster-of -Paris bandages are made. 

Flannel bandages are used solely to exert pressure, being 
particularly adapted for this purpose on account of their elas- 
ticity. This bandage is applied next to the skin without any 
intervening padding. Four inches is the usual width. 




Fig. 46. — Rolling bandage by hand. 

The bandage made of sheet rubber, known as the Esmarch 
or Martin bandage, is used at the time of operation to expel 
blood from a limb and to compress the vessels so as to prevent 
hemorrhage. They are made three inches wide. 

Triangular bandages, binders, slings and tailed bandages are 
made of unbleached muslin or of Canton flannel. The triangular 
bandage is made from a thirty-inch square of muslin folded or 
cut diagonally. Its principal use is as a sling for the arm. The 
four-tailed bandage is either a square of muslin, of suitable size 
for the purpose intended, with tapes at the corners, or is made 
from a strip of muslin bandage, split from each end with the 
scissors, leaving an uncut portion in the middle. Their principal 
use is for dressings applied to the chin, the eye or the ear. The 
8 



114 



MINOR TECHNIC IN SURGICAL NURSING 



forms and sizes of plain and many-tailed binders will be 
described in a later chapter. 

In making roller bandages muslin may be torn into strips of the 
desired width, but gauze, crinoline and flannel must be cut with the 
scissors. Gauze and crinoline are cut in line with the threads in the 
length of the goods. Flannel bandages are cut diagonally across 
the goods, the short pieces being then stitched together to make 
the requisite length. The object of this is to make them elastic. 




Fig. 47. — Bandage roller. 

Bandages may be rolled by hand (Fig. 46) or by means of 
one of the simple machines provided for the purpose (Fig. 47). 
Muslin and gauze bandages should be rolled as tightly as pos- 
sible. Crinoline and flannel bandages should be loosely rolled. 
All loose threads and ravellings should be carefully removed. 

IV. APPLICATION OF THE ROLLER BANDAGE. BANDAGING 
FOR THE RETENTION OF DRESSINGS 

The first consideration in bandaging for the retention of a 
surgical dressing is the character and distribution of the dressing 
material. From every fresh clean wound there will be for some 



BANDAGING 115 

hours an abundant discharge of watery fluid which oozes from 
the divided capillaries and is derived from the serum of the blood. 
In infected wounds there is a free discharge of pus or other form 
of inflammatory exudate. The dressing material must be of 
such a character as readily to absorb these fluid discharges and 
at the same time exert an elastic, non-rigid pressure in the 
neighborhood of the wound. To meet these indications there 
is nothing equal to the absorbent surgical gauze manufactured 
expressly for the purpose. The gauze is cut and prepared in 
various forms and sterilized in packages wrapped in muslin, or in 
metal drums (see page 275, Fig. 88) , and must be handled, of course, 
only with sterile gloves or instruments. The manner of applying 
the gauze dressings varies according to the amount of discharge 
from the wound. For the primary dressing of all operative and 
accidental wounds, and for all dressings of suppurating wounds 
the gauze used should not be in the form of pads, like a folded 
handkerchief, but in the form of fluffs, like a handkerchief shaken 
out and lightly crushed in the hand. The dressings should 
cover a rather wide area on all sides of the wound, six to eight 
inches at least, except, of course, in the case of very small wounds. 
The fluffs should be piled up to a thickness of from two to four 
inches or even more in the case of large wounds, and should be 
massed rather more heavily about the circumference of the 
wound and rather more lightly directly over the wound itself. 
When the wound is on an arm or leg a part of the gauze dressing 
should encircle the entire limb, which is best done by means of 
fluffs applied to the wound and over them a gauze roll wound 
about the limb. This applies also to dressing wounds of the neck. 
Wherever skin contact occurs, as in binding an arm to the side, 
abundant padding should be placed between the skin surfaces. 
When the gauze dressing has been applied it is well in some cases 
to secure it from slipping by means of strips of adhesive plaster 
which pass across the dressing and adhere to the skin on either 
side. Over all a gauze bandage of suitable width is now applied. 
In the case of abdominal wounds a binder takes the place of 
the bandage. The bandage should cover the entire dressing and 
extend a short distance beyond it on every side. It should be 
so applied as to have the proper grasp of the limb or other part, 
in order that it may not slip. This point will be referred to 
again in the discussion of regional bandaging. A dressing bandage 
should never be very tight, just sufficient tension being used to 



116 MINOR TECHNIC IN SURGICAL NURSING 

make it firm and secure. It should be, as a rule, about as tight 
as a comfortably fitting glove. Occasionally very much stronger 
pressure must be temporarily applied, principally for the purpose 
of controlling hemorrhage. Finally, the end of the bandage is 
twisted into a cord and fastened with a safety pin, preferably at 
a point directly over the wound itself, thus indicating its location. 
A small square of adhesive plaster also answers well for the 
purpose of fixing the end of the bandage. 

In cases where a certain amount of rigidity is desirable a wet 
crinoline bandage is put on over the gauze bandage. This, 
when dry, will give a moderately stiff superficial covering. For 
additional support, in certain cases, strips of thin, pliable wooden 
splints may be incorporated in the bandage. 

When the formation of pus is very abundant, or where there 
is a discharge of faeces, urine, or bile through the wound, the 
dressings must be changed very frequently and the means of 
holding them in place should be arranged so that the changes 
can be easily made. The use of short strips of adhesive plaster, 
two inches wide, attached to the skin on either side of the wound, 
with tapes fastened to them to tie across the dressings, will make 
it easy to remove the saturated gauze and replace it with a 
fresh supply. A binder pinned over this dressing gives additional 
security. In many cases when wet dressings are applied to a 
limb these must be changed every three hours or even oftener, 
and the roller bandage is too cumbersome a means for holding 
them in place. The wet gauze should be loosely folded about the 
limb, not wound around it with many turns; it should be cov- 
ered with a piece of oiled silk and held in place by means of a 
towel wrapped about the limb and fastened with safety pins or 
by three or four turns of a gauze roller. 

In the case of aseptic operative or accidental wounds there 
will be no discharge after the first few hours. For the second 
dressing of such wounds the requirements are, therefore, quite 
different from those called for at the first, since no provision 
need be made for the absorption of fluid material. Flat gauze 
pads may now be used, and these need not be so thickly piled 
or so widely distributed as at the primary dressing. 

V. BANDAGING FOR FIXATION 

In cases of fracture, of dislocation, and of disease involving 
a joint, the injured or diseased part must be kept at rest and in 
a fixed position for a considerable time. Fixation of a limb may 



BANDAGING 117 

be accomplished by means of padded splints held in place by 
strips of adhesive plaster and a gauze or muslin roller bandage 
or by means of bandages impregnated with some substance like 
plaster-of -Paris which will form a rigid covering for the injured 
part. The nurse may be called upon to apply some form of 
fixation apparatus as a first-aid measure, and it is very desirable 
that she should understand the principles governing their use, 
since a fixation bandage may be capable of doing serious harm 
when improperly applied. 

All splints or other fixation appliances should be well padded, 
especially over bony points. They should be put on tightly 
enough to ensure immobility but not enough to produce con- 
striction. The position of a limb should not be changed after a 
fixation bandage has been put on, since this may cause undue 
constriction at the point where the joint is flexed. The usual 
and normal position of the various joints in fixation is as follows: 
ankle, flexed at right angle; knee, straight; hip, straight; wrist, 
straight or slightly flexed; elbow, flexed at right angle; shoulder, 
in normal position at side. There are some exceptions to these 
rules; for example, the elbow must, for one fracture particularly, 
be put up in the straight position, and in many cases of fracture 
at the elbow-joint the best position is with the arm flexed at an 
acute angle; but these points are for the decision of the surgeon. 
In fractures of the shaft of a long bone the bone itself and the 
joint of either side must be included in the fixation. Some 
exceptions to this rule occur in the case of fractures close to a 
joint and in fractures of only one of the two bones in the forearm 
or leg. Fingers and toes, particularly the former, should always 
be left free in applying fixation to a limb, unless, of course, 
these are themselves the injured members. It is the most inex- 
cusable kind of bad surgery to include the fingers in a splint for 
a broken arm. They will inevitably become stiff and their 
restoration to their normal suppleness will be an extremely 
difficult matter. When the hand or foot below a fixation band- 
age becomes markedly swollen or cold and blue, the whole 
bandage, everything down to the skin, must be at once cut 
with the scissors, even, if necessary, without waiting for 
orders from the surgeon. After doing this, however, the 
fixation appliance need not be removed, a very loose band- 
age being put on over it until the surgeon has an opportunity 
to readjust it. 



IIS 



MINOR TECHXIC IX SURGICAL XURSIXG 



VI. BAXDAGIXG FOR PRESSURE 

Bandaging for the application of pressure may be required 
to control hemorrhage, or to give support and prevent swelling, 
as for example in ankle sprains and varicose veins of the leg. A 
pressure bandage must always extend from the toes or fingers 
up, leaving these free, otherwise swelling will occur below the 
bandage. Pressure must be elastic, not rigid, and therefore 
when either gauze or muslin bandages are used for pressure, 
padding must be applied between the bandage and the skin. 
Hospital wadding 'sheet cotton glazed on both sides) is the 
best material for this purpose. The diagonally cut flannel 




Fig. 4S. — Circular turns of a bandage. (Eliason's Practical Bandaging.) 

bandage is sufficiently elastic so that it may be used as a pressure 
bandage without any padding under it. The tension exerted 
by the pressure bandage must never be sufficient to interfere 
seriously with the circulation of the limb. Badly injured tissues, 
or those the subject of long-standing chronic disease, and the 
tissues of the very young or very old bear pressure badly. 

VII. THE •'• TURNS " USED IX BAXDAGIXG 

In order to make the folds of the roller bandage lie smoothly 
and with equal tension it is necessary to van- the manner of 
placing them in a number of ways as the bandage is wound in 
successive layers about the limb or other part. These various 



BANDAGING 



119 



turns are very simple in char- 
acter, but it is difficult to de- 
scribe them clearly, and they 
must be learned from pictures 
and by practical demonstra- 
tion. They are six in number 
and are known as the " circu- 
lar/' the "spiral," the " ob- 
lique," the " reverse," the 
"figure-of-eight," and the "re- 
current " turns. A bandage 
may be applied using one of 
these turns exclusively, or two 
or more in combination, or 
even changing from one to 
another at each successive 
encircling of the part with the 
bandage, unconsciously select- 
ing each time the particular 
turn that is best adapted to 
the case in hand, and forget- 
ting all the rules laid down in 
the text-books on the subject. 
This latter method is the usual 
practice with those who do 
much bandaging and gives the 
best results as regards effi- 
ciency, although not always 
the most finished appearance. 

The circular turn is one 
which simply encircles the part 
overlying the preceding turn. 
It is used principally to fix 
the free end of the bandage at 
the start (Fig. 48). 

The spiral turn is what its 
name indicates, each turn over- 
lapping the preceding turn with 
parallel edges (Fig. 49). It 
is applicable where the diam- 
eter of the part does not vary. 




Fig. 49. — Spiral and oblique turns. 
Practical Bandaging.) 



(Eliason's 



120 



MINOR TECHNIC IN SURGICAL NURSING 



In making the oblique turn the bandage is allowed to fall 
in any direction across the limb where it will lie smoothly, no 
attention being paid to uniform overlapping of the preceding 
turns. 

The reverse turn (Fig. 50) is made when it is found that the 
bandage, in order to lie flat, must be made to take a very oblique 
direction across the limb and the next turn will carry it beyond 
the area to be included in the bandage. The bandage is then 
" reversed," that is, turned over, making a diagonal fold across 
its width, so that what was the outer surface, away from the 




■■■m 



Fig. 50. — Making 

skin, now becomes the inner surface, towards the skin, and the 
course of the bandage takes a new direction. This turn is used 
where there is variation in the diameter of the part to be bandaged. 

The "figure-of-eight" (Fig. 51) really consists of two turns 
which cross each other at an angle on the front or back of the 
limb. A figure-of-eight bandage passing from the thigh to the 
trunk or from the arm to the shoulder is called a " spica " 
bandage (Fig. 52). 

Recurrent turns (Fig. 53) are made by folding the bandage 
back and forth upon itself, the bends of the folds being then 
caught by a circular turn. It is used in bandaging the head, 



BANDAGING 



121 




Fig. 51. — Figure-of-eight turns. (Eliason's Practical Bandaging.) 

covering in the ends of the fingers or an amputation stump 
(Fig. 54), making a suspender over the shoulder for a breast 
bandage, and so on. 



122 MINOR TECHNIC IN SURGICAL NURSING 

Vni. REGIONAL BANDAGING 

1. The Head. — Bandages of the head for the retention of 
dressings may include (1) only the scalp region, with the fore- 
head; or (2) the scalp region and the neck; or (3) in addition 
to these the chin may be included by turns which pass from the 




Fig. 52. — Spica of the hip. 



Fig. 53. — Recurrent of the scalp (first step). 
(Eliason's Practical Bandaging.) 



top of the head in front of the ear and under the chin, thus cover- 
ing everything but the face. In the first case circular turns pass 
under the occiput (Fig. 55) as low down as the hair line at the 
back of the neck and around the forehead, these holding recurrent 
turns which pass over the top of the head; or the scalp may be 




Fig. 54. — Recurrent bandage of the stump. 

covered by oblique and reverse turns caught under the circular 
turns. The ears should be left out, or, if included, padding 
should be placed behind and over each ear to protect it from 
pressure. When the neck is included, or the neck and chin, 
figure-of-eight turns are used crossing at the back of the neck 



BANDAGING 



123 





Fig. 55. — Recurrent turns. (Eliason' 
Practical Bandaging.) 



Fig. 56. — Figure-of-eight of the head and neck 
(Eliason's Practical Bandaging.) 





I Fig. 57. — Double oblique of the jaw. 
j (Eliason's Practical Bandaging.) 



Fig. 58. — Four-tailed bandage of the chin. 
(Eliason's Practical Bandaging.) 



124 



MINOR TECHNIC IN SURGICAL NURSING 



(Fig. 56) or under the chin, or at both these points (Fig. 57). 
Fracture and dislocation of the lower jaw are the only conditions 
calling for fixation bandages applied to the head. A four-tailed 
bandage over the point of the chin with the tails tied behind 
the neck and at the top of the head is the simplest appliance 
for this condition (Fig. 58). When the roller is used a sort of 
triple figure-of-eight with crossing points at the chin, at the top 
of the head, and at the occiput (Barton's bandage) (Fig. 59), 
or one with the crossing point at the chin, with turns to the back 




Fig. 59. — Barton's bandage. Fig. 60. — Gibson bandage. (Eliason's Prac- 

tical Bandaging.) 

of the neck, to the top of the head, and circular turns about 
forehead and occiput (Gibson's bandage), give good fixation and 
security (Fig. 60). 

2. The Neck. — Bandages for the retention of dressings 
including the neck alone are never used except for very slight 
and insignificant wounds, for which a few circular or oblique 
turns are all that is necessary. For wounds of any extent in the 
neck the bandage must include a number of turns about the head 
sufficient to secure the upper border of the neck bandage. Wounds 
of the lower part of the neck, and particularly those of the throat 
in front, will also require figure-of-eight turns passing down under 
both arms. Abundant dressings must be used here and the 
bandage must never be tight. Fixation appliances for the neck, 



BANDAGING 125 

required occasionally for disease or injury of the spine, must 
possess a firm grasp upon the whole trunk, neck, chin and head. 

3. The Thorax. — Extensive dressings are often needed here, 
particularly for operations on the female breast. Circular, spiral 
or oblique turns about the body with oblique turns from under 
the arm over the opposite shoulder and recurrent over the shoulder 
will be required. Wide gauze bandages should be used and care 
should be exercised that the turns about the chest are not too 
tight and that they do not extend too high under the arms. 
In extensive wounds (e.g., complete operation for cancer of the 
breast) the whole arm on the wounded side should be included in 
the bandage and fastened to the chest wall. Abundance of safety 
pins should be used to secure the folds of the bandage. Fixation 
for fracture of one or more ribs is often called for, and may be 
accomplished by means of a wide muslin roller, a tight binder, or 
wide strips of adhesive plaster. 

4. The Abdomen. — Dressings of wounds in this region are 
usually secured by adhesive straps and a binder, the roller bandage 
being rarely used, but bandages for the groin or thigh always 
include the lower abdomen to give them the proper grasp, and 
for wounds of the back in the lumbar region a wide gauze roller 
may be employed. Fixation appliances covering this region are 
always for injury or disease of the hip or of the spine. 

5. The Extremities. — In bandaging for the retention of 
dressings as applied to either the arm or leg, the figure-of-eight, 
spiral and oblique turns are the ones to be selected as a rule. 
The reverse will rarely be called for. Where simply the retention 
of a dressing, without pressure, is required, the figure-of-eight 
turn is to be preferred, since it will be found applicable to almost 
all situations, gives great security and at the same time the most 
finished appearance to the bandage. Circular and spiral turns 
will be resorted to where firm pressure is required, as for the 
control of hemorrhage, and recurrent turns in special situations, 
as for covering an amputation stump or the ends of the fingers. 
An occasional oblique or even a reverse turn may be called for, 
and a few circular turns to finish the edge of the bandage or to 
secure the recurrent turns. The use of the reverse turn will be 
mostly confined to the application of fixation appliances where 
the bandage must follow up a tapering limb (Fig. 61) covered 
with an even thickness of padding, as, for example, in bandaging 
over the adhesive straps in putting on a Buck's extension, and in 



126 MINOR TECHNIC IN SURGICAL NURSING 




Fio. 61. — Spiral reverse of lower extremity. (Eliason's Practical Bandaging.) 



BANDAGING 127 

applying a plaster-of-Paris cast for fixation of a fracture. The 
flannel bandage is used almost exclusively on the foot and leg 
(sometimes the wrist and arm) to give supporting pressure in 
cases of sprain or other conditions, such as varicose veins of the 
leg. It is to be applied from the toes up with figure-of-eight 
turns for the foot and spiral turns only for the leg, since this 
bandage stretches so readily that a reverse is never needed. 




Fig. 62. — -Velpeau modified (Dulles). (Eliason's Practical Bandaging.) 

Retention bandages for the shoulder, unless the wound is an 
insignificant one, should fix the arm to the side, with plenty of 
padding between the skin surfaces. There are two classical 
forms of bandage for securing the arm to the side, known as 
the " Velpeau " (Fig. 62) and the " Desault " bandages. In 
the former the whole arm is included, in the latter only the 
upper arm is fixed, the forearm being left uncovered and with 
some freedom of motion. The position of the arm for the Velpeau 



12- 



MINOR TECHXIC IX SURGICAL NURSING 



bandage is with the hand resting on the front of the opposite 
shoulder. The bandage consists of spiral turns about the body 
including the arm and forearm, with alternate turns passing 
over the shoulder on the injured side, from behind forwar :: = . 
and passing down under the arm and forearm. Desault's bandage 
is plie : with the arm lying straight across the body at the I 




Fig. 63. — Desault bandage. (FJiason's Practical Bandaging.) 



of the lower ribs. The bandage consists of circular and spiral 
turns about the arm and body, with a final roller applied 
compound figure-of-eight, having three points where the folds 
ig. 63), over the shoulder on the injured side, under 
the elbow and under the opposite axilla. In the classical de- 
scription a first roller fixes a pad in the axilla on the injured side, 
but this step need not usually be considered by the nurse in 



BANDAGING 



129 



cases where she may be called upon to apply the bandage. It 
must always be remembered, however, that plenty of padding 
is to be used to prevent contact of skin surfaces. Particular care 
must be exercised to avoid pressure over the point of the elbow. 




Fig. 64. — Finger bandage. 




Fig. 65. — Spica of the foot. (Eliason's Practical Bandaging.) 

The fingers are bandaged singly or two or more together, a 
three-quarter inch gauze roller being used with figure-of-eight 
and recurrent turns (Fig. 64). For the foot and ankle a simple 
application of the figure-of-eight is most suitable (Fig. 65). 
9 



130 MINOR TECHNIC IN SURGICAL NURSING 

In applying retention bandages to any part of the arm or leg, 
an ample area beyond the seat of injury should be covered and 
the bandage should be so adjusted as to have a proper grasp 
upon the limb so that it will not slip. To this end the bandage 
should always extend to or over one of the adjacent joints. A 
bandage of the upper arm should, as a rule, include a spica of 
the shoulder, the turns of which cross above the shoulder and 
pass under the opposite arm. A bandage of the thigh will require 
a spica of the hip to make it secure, the turns passing about the 
lower abdomen. Strips of adhesive plaster may at times be 
used to advantage to make a bandage secure, and the free use 
of safety pins at points where the folds are apt to slip is to be 
recommended. Retention bandages for the wrist and lower fore- 
arm should include the hand but leave out the fingers and thumb. 
The elbow should be bandaged in the position in which it is to 
remain, usually flexed. It should never be bandaged in the 
straight position, and flexed afterwards. Even a slight additional 
flexion of the elbow after a bandage has been applied may cause 
dangerous constriction. In bandaging the feet, the heel where 
it rests upon the bed should be protected by a ring pad. 

IX. PLASTER-OF-PARIS BANDAGES AND CASTS 

The Plaster=of=Paris Bandage. — The materials for these 
bandages will consist of a good quality of dental plaster and a 
rather wide meshed gauze or preferably crinoline cut into strips 
of the requisite width, usually 2J/£ to 4 inches. The plaster should 
be very finely ground, should feel very smooth to the fingers 
and absolutely free from grit. It should " set " within ten or 
fifteen minutes. The best material for the bandages consists of 
white crinoline such as is used by dressmakers, with a mesh of 
about 28 threads to the inch. If a cheap quality of crinoline 
is used containing an excess of dextrine in the starch the bandages 
will not set. 

Plaster bandages must be rolled by hand for the reason that 
they must be so loosely rolled that when immersed in water they 
will become rapidly and completely saturated. A machine- 
rolled plaster bandage will always be too tight. The core of the 
bandage should be an open cylinder the size of the finger. To 
prepare them properly the crinoline is cut on a thread to the 
requisite width and rolled, in ten-yard lengths. On a flat table 
or board a quantity of dry plaster and a spatula are placed. 



BANDAGING 



131 




Fig. 66. — Method of squeezing water from bandage. (Eliason's Practical Bandaging.) 




Fig. 67. — Making plaster bandages. (Eliason's Practical Bandaging.) 



:.. 



MIXOR TECHXIC ES SCBG1CAL MJBSXNG 




5 z. 
- - 
~ - 

% s 

:- 



= i 

r - 
o: 



BANDAGING 133 

The crinoline bandage is placed on the table and unrolled for a 
distance of about a quarter of a yard, with the free end toward 
the operator. Into this length of crinoline lying flat upon the 
table a sufficient quantity of plaster is rubbed with the spatula 
to fill all the meshes evenly. The free end is now turned into a 
cylinder about one inch in diameter, and is rolled across the 
table nearly as far as the plaster filling extends; it is then drawn 
back toward the operator and another length unrolled. This is 
in turn impregnated with plaster and the same process continued 
until the whole bandage is completed. Before beginning to roll 
each successive length the nurse should slide the impregnated 
roll one inch forward on the length of crinoline lying flat upon the 
table, thus insuring loose rolling. If this is not done the bandage 
will be too tight. A time-saving method consists in impreg- 
nating and rolling the entire width of the crinoline at one opera- 
tion, the long roll being afterwards cut into suitable lengths 
(Fig. 66). The completed bandages should be secured with pins, 
wrapped in thin paper and stored in a tin pail containing a small 
quantity of loose plaster and fitted with an air-tight cover. 

When the bandages are to be used they are placed on end, 
one after another as required, in a basin of water till air bubbles 
cease to appear. Each bandage as needed is lifted out, wrung 
fairly dry (Fig. 67), all ravellings removed, the free end separated 
from the roll and the bandage handed to the surgeon. Not more 
than one or two bandages at the most should be in the water at 
the same time. The water should be warm and deep enough to 
immerse the bandages completely. Care must be taken that no 
water is accidentally sprinkled into the container in which the 
unused dry bandages are stored. The removal of a plaster cast 
after it has set and dried is a somewhat tedious task at best. 
Various instruments have been devised for this purpose (Fig. 
68). The best means is a heavy-bladed knife. The operation 
is much easier if the line along the plaster cast where it is to be 
cut is softened with vinegar or other diluted acid. 



CHAPTER IX 
PREPARATION EOR THE TREATMENT OE FRACTURES 

1. The treatment of fractures consists essentially in the 
fixation of the broken bones in proper position long enough for 
bony union to occur at the seat of fracture. The usual period 
during which fixation is maintained is six weeks when the patient 
is an adult, a shorter time three to five weeks sufficing for 
children, whose bones heal much more rapidly. Two forms of 
external appliances are employed for the fixation of fractures: 
(1) the plaster-of-Paris cast, and (2) properly fitted and padded 
splints held in place by straps or bandages. In certain <:: a - 

^hts and pulleys are required in addition to overcome muscu- 
lar contraction, which tends to pull the fragments out of position. 
We may mention in passing ( 3 ) what is known as the open treat- 
ment of fractures, where an open operation is performed, an 
incision being made down to the seat of fracture and the fragments 
fixed in position by means of bone grafts or by wires passed 
through holes drilled in the bone or by steel plates fastened 
to the bone with screws or bolts. Cases of fracture where the 
patient is allowed to be up and walk about during the fixation 
period are spoken of as ambulatory cases. As a rule, fractures 
of the thigh and leg are the only ones among those enumerated 
which need confine the patient to his bed. and even some of : 
may be treated with advantage, by means of special apparatus, 
as ambulatory cases. The materials required for splinting a 
fracture may include (1) the fracture be 2 Lints, (3) padding. 
fixation (including straps, adhesive strips, band: ig s 
nes and . and sometimes (5) pulleys and weights. 

2. The Fracture Bed. — The first requisite for the treatment 
of a fracture of the hip. thigh or leg is a rigid flat surface for the 
patient to lie on. Xo such fracture can be treated properly on a 
bed tha T aaga A fracture bed consists simply of a rigid frame 

.pport the mattress. In the case of the usual form of hospital 
bed the purpose may be well served by the use of four boards, 
one inch thick, twelve inches wide and _ is the bed is wide. 

ae are placed across the bed frame under the wire springs, 
cleats being nailed to the ends to prevent slipping. Where a box 
134 



PREPARATION FOR TREATMENT OF FRACTURES 135 

spring is in use it must be discarded and a rigid wooden frame 
covered with a mattress substituted. The fracture bed is to be 
put in place before the patient is put to bed in all cases of frac- 
tures of the lower extremity. 

3. Splints. — A variety of materials are employed for these. 
Wood, metal, felt and binder's board are the most common. 
Flexible wooden splints, of the thinness of veneer, are used by 
surgeons for many purposes. They can be broken or cut with 
scissors to any convenient shape and used singly or in several 
thicknesses as desired. Rigid wooden splints, from Ke to ){ inch 
thick, may be cut with a knife or saw to fit any particular case, 
and separate pieces may be fitted together, when necessary, 
with nails, screws or brackets. Metal splints may be of wire 
or sheet metal. Many forms are manufactured moulded into 
various shapes ready for use. Felt used for splints is impregnated 
with gum or shellac to give it stiffness. It comes in sheets and 
may be cut to fit, softened by heat and moulded to any shape 
desired. On cooling it becomes rigid in the moulded form. 
Binder's board, or pasteboard, is used as a makeshift for the 
temporary fixation of fractures, and sometimes as an additional 
support in certain cases. 

The nurse should be familiar with the names of several com- 
mon forms of splints. The right-angle elbow splint is commonly 
inaptly called the "internal angular" splint. It is really an 
anterior right-angle splint, fitting over the front of the arm and 
forearm and bend of the elbow. It is usually made of three 
pieces of tin soldered together, two pieces slightly rounded to 
fit the arm and forearm, with a "gusset" set in at the elbow. 
The internal angular splint, properly so-called, has the angle 
"on the flat" like a carpenter's square, and fits the inner side 
of the arm and palmar surface of the forearm. It has a round 
hole at the angle to avoid pressure on the internal condyle of 
the humerus. When dorsal and palmar splints for the fore- 
arm are called for, two pieces of splint wood, long enough to 
reach from the elbow to the base of the fingers and a little wider 
than the arm, should be provided. The surgeon will trim them 
to the proper dimensions and shape. A posterior leg and foot 
splint fits the back of the leg and has a piece at right angles to 
this which rests against the sole of the foot. It may extend to 
the knee or to the middle of the thigh. It may consist of a wire 
frame wound with bandage (Cabot's), or it may be made of 



136 MINOR TECHNIC IX SURGICAL NURSING 

woven wire or wood. A wooden splint of this form, fitted with 
grooves on the under side to slide on a flat board or frame resting 
on the bed, is known as Volkmann's sliding rest, and is used 
when extension is applied to fractures of the thigh. 

A posterior knee or ham splint is a splint fitting the leg and 
thigh back of the knee with the object of immobilizing that joint. 
It may be made of a straight piece of wood about twenty inches 
long and four inches wide, well padded, or it may (better) be 
of wood or metal shaped to fit the curves of the leg. The axillary 
or long side T-splint is a long wooden splint applied to the side 
of the body extending from the foot to the axilla, used in cases 
of fracture of the thigh and hip. It usually has a short cross- 
piece nailed to the posterior edge of the lower end to keep it 
from turning. For an adult it will be about four feet ten inches 
long, four inches wide and % of an inch thick. Coaptation splints 
are short, narrow wooden splints which are laid close together 
about the circumference of a limb and held by straps in order 
to exert equal pressure from all sides. They are applicable only 
to the upper arm and thigh, where but a single bone exists, never 
to the forearm and leg. The shoulder cap is used by some surgeons 
as an adjunct in the treatment of fractures of the humerus near 
the shoulder-joint. It is not a true splint, its purpose being 
simply to guard the shoulder and to distribute evenly the pressure 
of the bandage which holds the arm to the side. It is made from 
a piece of binder's board 10 by 16 inches. It is first bent into 
the form of a half cylinder. One straight central cut. and two 
curved slanting cuts at the top enable this portion to be folded 
over in the form of a dome covering the shoulder, the overlapping 
pieces being fixed by some means, such as needle and thread, 
safety pins or paper fasteners. The lower six inches in front are 
cut away where the cap fits over the bend of the elbow. 

4. Padding Splints. — The materials for padding are cotton 
wadding (preferably that sold by the trade under the name of 
ho-pital wadding, which has a double glazed surface), felt, folded 
towels and >hepts. with adhesive plaster and bandages to fix the 
pad. Felt is the best material to pad splints, but also the most 
Dsfrre. Toweling i> used for certain special pads and some- 
rime- to pad temporary splints in emergency. For a straight 
len splint six or more thicknesses of hospital wadding are 
r folded to make a pad large enough to project a half inch 
over the edge of the splint. The pad is fixed to the splint with 



PREPARATION FOR TREATMENT OF FRACTURES 137 

three narrow strips of adhesive plaster and the whole covered 
neatly with a gauze roller bandage or, better, with a single piece 
of cotton cloth stretched smoothly over the padded splint and 
neatly stitched in place. A ham splint must have extra padding, 
2 inches thick, under the knee. All the flat wooden splints 
should be padded to fit the limb; that is, the padding should 
be made thicker where needed to fit the hollows. It is better, 
when possible, to do the fitting on the sound side in order 
to avoid unnecessary handling of the fractured limb. In padding 
splints the body prominences, such as those at the wrist, elbow, 
ankle and heel, must be particularly looked after. Pressure on 
these points, even if continued only for a few hours, may result 
in sloughing of the skin. The splints must be cut away over these 
points or the padding adjusted to guard them. The heel is par- 
ticularly susceptible where it rests on the bed, carrying part of 
the weight of the foot and leg. For protection of the heel the 
ring or "doughnut" pad must be used with every form of splint 
or plaster cast applied to this region. This pad is made of cotton 
wound with a narrow gauze bandage. It is exactly the size and 
shape of the common doughnut. 

Fractures of the upper arm are treated by means of coaptation 
splints and with the arm bandaged to the side. A pad must be 
placed between the arm and side, and this is known as an axillary 
pad. It extends from the axilla to the elbow, and in some cases 
may be wedge-shaped. A strip of bandage passing over the 
opposite shoulder, or adhesive plaster, prevents it from slipping 
down. The axillary pad may be made of cotton, but is better 
made of folded towels. A folded towel is also the best pad for 
coaptation splints. When it is used the splints themselves are 
not padded, but a smooth towel is folded in four to eight thick- 
nesses and wrapped smoothly about the limb. The coaptation 
splints, narrow pieces of thin wood one inch wide, are then laid 
over the towel and strapped in place. 

5. Materials for Fastening Splints. — Straps of webbing, one 
inch wide, with a buckle sewed to one end, or strips of adhesive 
plaster one to two inches wide, and long enough to encircle the 
limb and splints one and a half times, are used for this purpose. 
A roller bandage of gauze or muslin is usually applied over the 
whole for additional security and protection. There is sometimes 
a little difficulty in passing the strip of sticky adhesive plaster 
under and about the limb without becoming twisted and kinked 



138 MINOR TECHXIC IX SURGICAL XURSIXG 

before it has been properly adjusted. This minor annoyance 
can be easily prevented by a verj T simple expedient. A piece 
is cut from a roller bandage twice the length of the adhesive 
strip, folded end-to-end and laid on the adhesive side of the strip. 
The whole is next passed under and about the limb and adjusted 
to the proper position. The bandage is then removed by pulling 
on the free end. The end of the adhesive strip should be folded 
on itself for a quarter of an inch to facilitate removal. 

6. Apparatus for Extension. — This is used almost exclusively 
in cases of fracture of the thigh. It is commonly called Buck's 
extension. A strip of adhesive plaster is applied to each side 
of the leg, extending from the middle of the thigh to the ankle, 
these strips being held in place by means of other strips of ad- 
hesive passed spirally about the leg and a roller bandage. The 
lower ends of the strips are attached to a weight by means of 
a cord passing over a grooved pulley at the foot of the bed. A 
wooden cross-piece or " spreader " is placed an inch or two below 
the sole of the foot to prevent the straps from pressing on the 
ankle bones. The foot of the bed is elevated about six inches 
to counteract the tendency of the patient to slide down. The 
extension straps with the spreader require some little time to 
prepare and should therefore be kept in stock ready for use. 
To make a set of suitable size for an adult two strips of adhesive 
plaster two inches wide and twenty-six inches long are cut, the 
gauze facing on the adhesive side being, of course, left in place 
until the strips are used. One end of each strip is folded to pass 
through the shank of a one-inch buckle to which it is securely 
sewed. A strap of webbing one inch wide and fourteen inches 
long is next provided. The spreader is fastened to the middle 
of this strap. A simple and convenient way for making the 
spreader consists in cutting two pieces of splint wood, V/i by 33^ 
inches in dimension?, the middle of the strap being placed between 
these and fastened by winding them with adhesive plaster. At 
the exact centre of the spreader (that is, where lines joining the 
opposite corners cross) a l 4-inch hole is bored. One end of a four- 
; >iece of window cord is passed through this hole and knotted. 
The pulley wheel will be attached to an iron rod which is provided 
with a clamp to fix it to the foot of the bed frame and allow it to 
be adjusted to any desired position. Weights up to twenty 
pounds should be available (Figs. 69-70). 

The ward should be provided with the means of setting up 



PREPARATION FOR TREATMENT OF FRACTURES 139 

an overhead frame which will be needed in a number of condi- 
tions where overhead suspension of a limb is desirable. The 
frame consists of an upright piece b}/2 feet long securely fixed 
at the head of the bed and another, somewhat shorter, at the foot, 
the tops being joined by a third piece securely fastened to them. 




Fig. 69. — Buck's extension. (Eliason's Practical Bandaging.) 

The frame may be of wood or iron and must be sufficiently rigid 
to support any ordinary weight. The Bradford frame will be 
needed as an aid in the treatment of fractures occurring in young 
children, as well as in orthopaedic- cases. It consists of an oblong, 




Fig. 70. — Dressing for fracture of the shaft of the femur. 

stretcher-like frame a little longer and wider than the child's 
body. It is made of gas pipe and covered with canvas. 

7. Temporary Fixation of Fractures. — It is often desirable 
for a number of reasons to postpone for from one to several days 
the attempts at reduction and the permanent dressing of a frac- 



140 MINOR TECHNIC IN SURGICAL NURSING 

ture. There is often excessive swelling of the soft parts about a 
fracture, lasting for some days. An anaesthetic must frequently 
be administered when reduction is attempted, and for this it is 
desirable that the usual preparation should be given. Time is 
needed for the taking and proper study of X-ray pictures. Since 
the patient's interests are not jeopardized, nor the final union 
postponed by a reasonable amount of delay, it is entirely proper 
to wait for a suitable and convenient time, provided that in the 
meantime the limb is kept at rest by some suitable means. A 
full description of these temporary appliances will be given in 
the chapter on emergencies. 

8. Permanent Fixation of Fractures. — The materials that are 
to be assembled by the nurse for the permanent dressing of the 
principal varieties of fractures are here briefly summarized. 
Warm water, soap, alcohol and talcum powder will be needed for 
the preliminary cleansing in all cases. When a plaster-of -Paris 
cast is the means selected a rubber sheet to protect the bed or 
table on which the patient is lying will be needed. An apron 
and a pair of rubber gloves should be provided for the surgeon, 
or, if he prefers to use his bare hands, some hand lotion, contain- 
ing glycerine or dilute acid (vinegar), for removing the plaster 
from his hands. A number of rolls of hospital or sheet wadding, 
a ring pad for the heel, when the foot is to be included; some 
thick harness maker's felt; gauze bandages (2-, 3- and 4- inch 
sizes); an abundance of plaster bandages of at least two sizes; 
some common salt; and a basin of water deep enough to allow 
the largest plaster bandage to be immersed when standing in 
the upright position will be required. When the fracture is to 
be immobilized by means of splints the surgeon will indicate 
the particular forms he desires to employ. Abundant material 
for padding, adhesive strapping, gauze and muslin bandages 
should be at hand. For putting up a fractured thigh in Buck's 
extension the following articles should be assembled: the ready 
prepared extension set, consisting of adhesive straps with buckles, 
webbing strap and spreader; four feet of window cord; the pulley 
wheel, with its attachments; from eight to twenty pounds of 
weights, according to the age or size of the patient; blocks or 
bricks to elevate the foot of the bed; Volkmann's sliding rest; 
axillary long side T- splint; coaptation splints for the thigh; 
six webbing straps with buckles sewed to one end long enough 
to extend once and a half about the thigh; adhesive plaster; a 



PREPARATION FOR TREATMENT OF FRACTURES 141 

sheet (for the long splint), towels and cotton wadding for padding; 
a ring pad for the heel; several yards of muslin or Shaker flannel 
to make swathes to hold the long splint to the body and thigh; 
and plenty of safety pins. If the Volkmann rest is not used a 
properly padded ham splint, a rubber sheet to lay over the bed 
under the splint, and four sand bags, 20 inches long by four 
inches wide, must be provided. For a fractured clavicle in an 
adult, three strips of adhesive plaster, four inches wide and long 
enough to extend once and a half about the body; three towels; 
rolls of sheet cotton wadding; four inch gauze bandage; three- 
inch muslin bandages; and four-inch crinoline bandages will be 
needed. 

For fractured ribs, a four- to six-inch muslin roller or four 
strips of adhesive plaster, four inches wide, and equal in 
length to three-fourths of the circumference of the chest, should 
be provided. 

9. Observation After Dressing of Fractures. — All fracture 
cases must be closely watched for at least the first twelve hours 
after a fixation dressing is applied. Continued pain at the seat 
of fracture or over a bony prominence calls for serious attention 
from the surgeon. Blueness and coldness of the extremities 
below the bandage (fingers and toes), with or without swelling, 
calls for instant relief of pressure, even to the extent of cutting 
through the whole bandage down to the skin. 



D91 



CHAPTER X 

REMEDIAL MEASURES 

I. MEASURES REQUIRING SIMPLE CLEAXLIXESS 

Ix the preparatory, post-operative and routine treatment of 
gynaecological patients, there are a number of measures for the 
relief, cure or comfort of the patient that do not require the 
strictest technic. — and it seems fitting that these should receive 
consideration in a separate group,, so that, by no chance,, could 
they be extended to include those of a stricter order. 

1. The enema has alreadj^ been referred to upon several 
occasions in its connection with preparatory and after-treatment. 
While the average enema does not require adherence to the most 
careful technic in its administration, it must be realized that 
this leeway does not admit of careless or unclean methods. The 
enema can. tube and tip should be cleansed by mechanical methods 
after each use. The tip should be sterilized as well as mechanically 
cleansed before putting away. This is particularly true in hospital 
work, where a large series of patients must necessarily include 
some from whom dangerous infections might be transferred to 
innocent persons if these precautions were not taken. In per- 
forming the manipulations necessary for the administration of 
an enema, it should not be forgotten that there is as much a 
right and wrong way of doing this as of any other treatment. 
There seems to exist in some minds the impression that giving 
an enema means taking a can with the usual accessories: filling 
with the prescribed solution; inserting the tip; lifting the can to 
the extreme limit of the tube or of the nurse's arm: removing the 
tip; and going off and leaving the patient upon a bed-pan until 
it is convenient to remove the same. Strange as it ma}' seem, 
there are several fallacies in these conclusions. There are a 
number of elements that enter into the use and administration 
of enemata that should be considered before the subject is referred 
to the limbo as one of no difficulty and little importance. In 
the first place, there are at least three positions in which enemata 
may be administered, according to the result desired and the 
preference of the attendant: the dorsal, the left lateral and the 
142 



REMEDIAL MEASURES 



143 



knee-chest. No matter what the position, the general details 
followed in each case are very much the same. The enema 
formula is prepared in the can. The patient is placed in the 
desired position and the tip inserted with the aid of a little vase- 
line or other lubricant. The passage of the rectal or colon tube, 
while of apparent simplicity, may be done in such a way as to 
add much to the discomfort of the patient and the difficulty of 
the procedure. The general outline and direction of the anal and 
rectal canals (Fig. 71) should be borne in mind and the tip 




Rectum 



Anus 



Fig. 71. 



-Median Bection of female pelvis. The difference in direction of anus and rectum 
should be noted. 



directed thus along the line of least resistance, instead of forced 
in a straight line. This means that the tip must be inserted first 
in an anterior direction until it has passed the sphincter and is 
in the rectum. The direction is then changed, the tip being 
pointed backward and passed in such a manner as to somewhat 
follow the curves of the sacrum. The passing of the colon tube 
beyond this point frequently requires considerable patience and 
ingenuity of manipulation. The sigmoid leaving the rectum at 
an angle towards the left, the tube, being long and soft, must be 



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evacoanioii of the bowels- is 

off ike 




REMEDIAL MEASURES 145 

sulphate, two ounces of glycerine and three ounces of water or 
soapsuds. This is commonly called a " one, two, three " enema. 
Another well-known routine purgative enema is composed of the 
same ingredients in larger quantities and named accordingly. 
This is the " two, four, eight " enema, consisting of two ounces 
of a saturated solution of magnesium sulphate, four ounces of 
glycerine and eight ounces of water or soapsuds. Turpentine 
may be added to either of these enemata, in varying quantities — 
as much as half an ounce being added to the larger. 

Nutrient enemata are given when, for any reason, mouth 
feeding must be temporarily abandoned and the condition of 
the patient necessitates the continued ingestion of supporting 
food. On account of rapidly developing irritability of the larger 
bowel, this treatment is, at best, not feasible for extended periods. 
On account of the limited digestive capacity of the large bowel, 
the range of nutriment to be employed is necessarily curtailed. 
Nutrient enemata must, therefore, be, so far as possible, of the 
most readily assimilable and the most slightly irritating possible 
ingredients. The most common ingredients are milk (plain or 
peptonized), eggs, sugar (grape or cane), red wine and salt, — 
varying in proportion to make a maximum total quantity of 
eight or nine ounces. One of the simplest is the sugar and milk 
enema, consisting of: 

Grape sugar 60 gm. 

Peptonized milk 250 c.c. 

A more complicated one is that of Boas, consisting of: 

Milk 250 c.c. 

Yolks of two eggs 
Pinch of salt 

Red wine 15 c.c. 

Starch or flour 15 gm. 

2. Rectal Irrigation. — There is very little to be said of rectal 
irrigation that has not already been referred to under the dis- 
cussion of enemata. The preparation of rectal irrigation is the 
same as that for the enema, except for the substitution of a 
glass or enamel-ware funnel for the enema can. The funnel is 
then filled with the solution that is to be used and the solution 
run into the rectum by elevating the funnel to the necessary 
height. This proceeding is repeated several times, until the 
rectum has been somewhat distended by the solution, when the 
funnel is lowered and permitted to fill with the solution running 
10 



MINOR TECHXIC IX SfRGlCAL XURSIXG 

back from the rectum.. The contents from the funnel are then 
poured into a receptacle provided for the purpose and the pr 

sated, time and again, until the rectum has been emptied. 
7__: ; treatment is continued until the rectum has been cleansed, 
if that is the object of the irrigation, or until the application 
has been sufficient for the purpose in view, whatever it may be. 
Edition to the above apparatus and method, mention might 
be made of the double-channel rectal or colon tube, that permits 
of the return of the fluid by one channel as fast as it enters by 
the other. 

3. Continuous Proctoclysis Murphy Method for Rectal Salt 
Solution . — The application of the principles of this method of 
treatment is sc varied with different physicians and in different 
hospitals that it would take a small book to go into the details 

: each different apparatus and the method of using it. But the 
end to be attained is in each case the same, so that a general 
rlption of the principles involved appears proper in this place. 
The object is the introduction into the rectum of a physio- 
logical salt solution at the temperature and rate at which it will 
be most rapidly absorbed. The method is of the g: -.. test :due, 
and ix is : _ . meiy important for both nurses and internet tc 
know how to give it properly. It is a frequent experience of 
surgeons when ordering this treatment to have it reported that 
the patient is unable to retain the saline solution, and this is 
due in the great majority of instances to faulty methods of admin- 
istration. T^e requisH es ait I that the fluid should be warmed. 

_ that it should flow drop by drop, about one-half pint entering 
the rectum each hour. 3 that there should be a free return so 
that when the rectum contracts the gas and fluid which are 
present may flow easily back through the tube and not be expelled, 
form of apparatus first suggested by Dr. Wroth ,Fig. 72 
is the simplest and best and can be readily improvised anywhere. 
A glass or metal funnel is connected by about four feet of rubber 
tubing and a glass connection tube with a small or medium-sized 
catheter. The catheter is introduced into the rectum and fixed 
to the inner side of the thigh by a strip of adhesive - 
funnel is suspended by the side of the t a height of about 

6 to 14 inches above the level of the buttocks. The irrigator 
containing the saline solution is suspended above the funnel and 
is furnished with b "-rminating in a stop- 

so adjusted that the fluid can be allowed to flow drop by drop 



REMEDIAL MEASURES 



147 



into the funnel. The fluid is warmed just before it enters the 
rectum by placing a coil of the tube which joins the funnel and 
the catheter between two hot-water bags lying on a table beside 



Graduated glass container 
for saline solution 



Stop-cock to regulate flow 
drop by drop 



Plain glass funnel con- 
nected directly with 
rectal tube 




Rubber tubing 



Glass tube connection 



Rubber catheter to be 
introduced into rectum 



Fig. 72. — Apparatus for proctoclysis. 



the bed. About 60 to 80 drops per minute is the proper rate of 
flow. It is sometimes difficult to regulate the flow exactly. To 
facilitate this a shallow notch should be filed at the edge of the 



14S 



MINOR TECHXIC IN SURGICAL NURSING 



opening through which the water flows in that part of the stop- 
cock which is turned by the finger and thumb (Fig. 73). In an 
improvised outfit the tube from the irrigator may be compressed 
by means of two flat sticks and rubber bands, the sticks being 
wedged apart to regulate the flow. 

4. Active and Passive Congestion. — Several methods de- 
signed to influence the flow of blood to a part are frequently 
resorted to in the treatment of surgical cases. These include the 
use of moist and dry heat, constriction of arms or legs by rubber 
bands to induce passive congestion by obstructing the return 
flow of blood through the veins, and the use of cups of various 




Fig. 73. — Showing notch filed in stop-cock to facilitate regulation of rate of dropping. 

forms in connection with a small suction pump by means of which 
passive congestion may be induced in parts of the body surface 
where constriction is not available. The application of heat in 
either moist or dry form causes what is known as active conges- 
tion; that is, it induces a dilatation of the small arteries and pro- 
duces an increased flow of blood to the part. Moist heat is applied 
by means of hot fomentations. Dry heat is applied by means 
of hot air. The arm or leg, for example, is wrapped in blankets 
and placed in a double-w r alled chamber or oven (supported so 
that the limb does not come in contact with the walls of the 
chamber) in which the air is heated by means of a gas jet up to 
250° or 300° F. Passive congestion, on the other hand, consists 



REMEDIAL MEASURES 149 

not in increasing the flow of blood to the part, but in allowing 
blood to accumulate in the part by partly obstructing the return 
flow, and the methods of doing this by means of constricting bands 
and cups are known as Bier's hypersemic treatment, employed 
in acute and chronic (tuberculous) infection. The apparatus 
for constricting a limb consists of an Esmarch bandage or rubber 
tube tourniquet applied over a smooth folded towel wrapped 
about the limb. The treatment is intermittent, the constriction 
being maintained for from one to several hours, the bandage 
being then removed for a time and later reapplied. As the nurse 
may at times be entrusted with its application and must in any 
case observe the condition of the limb during the period of con- 
striction, it is important for her to bear in mind the following 
points. The band should be applied over healthy tissue well 
above the seat of the disease; it should moderately constrict the 
veins of the part, so as to diminish but not stop the return flow 
and without affecting the volume of the pulse; the skin below 
the constriction should be of a slightly bluish-red color and 
warmer to the touch than normal; there should be no pain. If 
there is much swelling, and the skin is blue and cold, or if there 
is pain, then the constriction is too tight and must be loosened 
or removed for a time. It is better to change the location of the 
constriction at each application. A great variety of cups are 
manufactured for the production of local hyperemia at different 
areas of the body surface, for the treatment particularly of local 
infections, such as furuncles, carbuncles, abscesses, etc. At least 
two or three sizes of some of the simpler forms of this apparatus 
should be available; for the application of this method the proper 
cup attached with rubber tubing to a rubber bulb or small hand 
pump to produce suction, and some sterile vaseline to make the 
edge of the cup air-tight, will be needed. In this case the hyper- 
emia is continued for short intervals only (five minutes) at a 
time, with five to ten reapplications at each treatment. If there 
is a wound the cup must be sterilized before and after use. 

5. Continuous Irrigation. — Long, deep basins of special form 
are made for the purpose of immersing the hand or foot in water 
or a weak antiseptic solution for the treatment of infections of 
severe type by means of the continuous bath. Where special 
apparatus of this kind is not available an ordinary foot-tub may 
be pressed into service. The treatment may be applied to the 
whole body by means of the ordinary bath-tub or special tubs 



1.50 MINOR TECHXTC IX SURGICAL XURSIXG 

which are now made for this purpose. The water should be at a 
temperature of 105° to 110° F. In other cases continuous irri- 
gation by the drop method may be used. A Kelly pad. draining 
into a basin, an irrigator with irrigating stand, and rubber tubing, 
and a pinch cock or other means to regulate the flow will be 
required. 

6. The Fowler Position. — After certain abdominal operations, 
particularly suppurating appendix cases, it is at present the 
almost universal custom to place the patient in bed in the so- 
called Fowler position, that is. in a semi-sitting posture; and to 
do this some special apparatus must be provided. One of the 
best is known as the Gatch bed. an iron frame placed under the 
mattress and capable of lifting it at the patient's back and under 
his knees into the form of a reclining chair. An apparatus may 
be improvised by the use of a back rest, a bolster made from a 
pillow tightly rolled in a sheet placed under the buttocks, with 
the ends of the sheet tied to the bed frame to preA'ent the patient 
from slipping down in the bed. a rolled pillow as a brace for the 
feet, and supporting pillows under the knees. 

7. Special Forms of Dressings. — " Wet dressings " are used in 
the treatment of accidental and infected wounds. The gauze 
is wrung out of an antiseptic solution. Usually 1-10000 bichloride 
or boracic acid solution is employed. The dressing may be 
covered with oiled silk to prevent evaporation. 

The " hot pack " takes the place of the old-fashioned poultice. 
The dressings are wrung out of hot sterile water or salt solution 
and are changed frequently before the water has become cold. 
This is a very efficient way of treating acute suppurative processes. 

Bismuth paste which is used for the injection of sinuses is a 
mixture of subnitrate of bismuth and vaseline. It is semisolid 
at ordinary temperatures, and must be liquefied when it is to 
be used, by warming over a water bath. A glass or metal syringe 
of suitable size, alcohol, small sterile pads of gauze and adhesive 
plaster will be required. 

Unna's paste is used in the treatment of leg ulcers. The 
bams of the paste is gelatine mixed with oxide of zinc. It is 
solid at room temperature, but melts at a low heat. When in 
the liquid form it looks like white paint. A quart or more of the 
paste, melted over a water bath, a medium-sized paint brush, 
alcohol, sponges and a number of two-inch gauze bandages will 
be required. 



REMEDIAL MEASURES 151 

In the dry treatment of burns no dressing whatever is applied 
over the burned surface, which is fully exposed to the air. Burns 
so treated heal more rapidly and with less scar formation than 
when wrapped in an occlusive dressing. The pain of frequent 
change of dressings, often very severe, is also avoided. For a 
burned arm or leg there will be needed: a pillow covered with 
rubber sheet and sterile towels and a cradle or wire frame over 
which is thrown a single layer of gauze which does not touch 
the burned surface but merely acts as a fly screen. Cleansing 
is done as needed with dry sponges. 

II. ROUTINE MEASURES REQUIRING ASEPTIC TECHNIC 

In addition to those measures executed by the nurse that 
have already been enumerated as of a kind requiring mechanical 
cleanliness alone, there are several that demand as strict an asep- 
tic technic as any of the procedures of major surgery. These 
are generally, if not always, performed by the nurse, and she 
should constantly bear in mind her responsibility to patient and 
physician for the proper care and precautions in every such case. 

1. Hypodermic Medication. — We have already made some 
passing reference to the generally accepted inexcusability of 
abscess following hypodermic medication. While admitting with- 
out hesitation that such abscesses will occur when, apparently, 
every possible precaution has been taken, yet the fact remains 
that suspicion of the care and technic of the administrator invari- 
ably follows the appearance of this unfortunate complication. 
The technic of administration, while exacting, is of the simplest, — 
whence, possibly, the carelessness that makes the occasional 
infection a possibility. The steps are four: (a) preparation of 
the syringe; (6) preparation of the solution; (c) preparation of 
the patient; and (d) administration of the injection of the medica- 
ment. The division of such a simple performance into parts 
may seem like the making of a mountain out of a mole-hill, but 
it remains true in nursing as it has of all admirable branches of 
the world's work that what is worth doing is worth doing well. 

(a) The best type of syringe for general use is the all-glass 
instrument that will permit of the instrument being repeatedly 
sterilized by boiling and permit the contents to be seen. It is 
best to boil the entire instrument before using, but, if this be 
not feasible, the needle should be boiled, a wire being kept run 
through the lumen to prevent clogging by rust. 



152 MINOR TECHNTC IN SURGICAL NURSING . 

(6) A small amount of water is then sterilized by boiling over 
a flame in a teaspoon or other convenient receptacle. The 
syringe is then drawn full of the sterile water and the remainder 
thrown away. The contents of the syringe are then once more 
discharged into the spoon and a hypodermic tablet containing 
the prescribed dosage of the medicament is dissolved in the water 
and the solution drawn into the syringe. 

(c) The patient's arm is then scrubbed with a sterile gauze 
sponge and 95 per cent, alcohol, over the area of injection, a 
point on the upper arm in the region of the humeral insertion 
of the deltoid muscle being the usual point of election. 

(d) A small bit of skin is then pinched up between the thumb 
and index finger of the left hand and the hypodermic needle 
quickly inserted. The needle is withdrawn about % of an inch 
and the solution slowly injected. The needle is then slowly 
withdrawn, the point of injection being covered and then lightly 
rubbed with the alcohol-saturated sponge. 

2. Catheterization of Patient. — The importance and responsi- 
bility of this procedure have already been touched upon in our 
remarks upon post-operative treatment. We shall, therefore, 
confine ourselves, at this time, chiefly to a discussion of the ideal 
technic and the variations thereof that are commonly resorted 
to for the purpose of lessening the time and tedium where numer- 
ous catheterizations are necessary. 

The outfit for catheterization should consist of: (a) a sterile 
glass or rubber catheter; (6) sterile sponges; (c) a basin of sterile 
water; (d) a basin of 1-1000 bichloride solution; (e) a receptacle 
for the urine; and (/) a pair of rubber gloves or four finger cots 
for the nurse. All materials should be perfectly sterile. A small 
jar of sterile glycerine, or other lubricant, is sometimes added 
to the above outfit. The preparation of the patient consists in 
the careful cleansing of the vulva and the area around the urinary 
meatus, first with sterile water and then with bichloride solution. 
The preparation of the nurse consists in careful scrubbing of the 
hands, as for operative work, and the additional use of sterile rubber 
gloves or of sterile rubber finger cots upon the thumb and index 
finger of each hand. After the careful preparation of patient and 
nurse, the labia are well separated with the thumb and forefinger 
of the left hand and the catheter introduced with the correspond- 
ing finders of the other hand. After the withdrawal of the 
catheter, the parts should again be sponged off with bichloride. 



REMEDIAL MEASURES 153 

The variations that are resorted to for the purposes of render- 
ing this proceeding less exacting are generally with respect to the 
preparation of the nurse, the preparation of the patient remaining 
the same. In such cases, the scrub is sometimes omitted, — con- 
fidence being placed in the protective power of the gloves. In 
others, finger cots are used, without the scrub. In others, pieces 
of sterile or bichloride soaked gauze are substituted for either 
gloves or cots, and the scrub is, of course, again omitted. Yet 
another evasion of the most careful technic is the use of a steril- 
ized forceps to grasp and insert the catheter, this instrument 
taking the place of both scrub and gloves. These methods are 
mentioned because they are frequently observed in hospitals 
where the authorities would feel insulted if any question were 
raised regarding the perfection of their aseptic technic, and with 
the view of condemning, not condoning. It is true that our 
methods are more or less dependent upon our supplies and 
surroundings, but the duty is ours to see that our methods are 
either the best that we know or the best that we can attain under 
existing conditions. Unless we attain this requirement of every 
conscientious physician or nurse, we must consider ourselves 
directly responsible for any unsavory results of our work. 

3. Bladder Irrigation. — Bladder irrigation, by the nurse, is 
for the purpose of removing infectious and cast-off material from 
the bladder and for applying remedial agents to its lining mem- 
brane. The apparatus for its proper performance consists of a 
sterile glass funnel with tube attached; a rubber catheter and 
glass joint for connecting it with the tube and funnel; a receptacle 
for receiving the return flow from the irrigation, and a pitcher 
of the chosen solution. The solution used may be of any one of a 
number, ranging from sterile water, through physiological salt 
solution and boracic acid solution, up to the stronger antiseptics, — 
as potassium permanganate, silver nitrate and protargol. The 
solution should be warm, but not hot, — a temperature of between 
100° and 105° F. being about the best. The technic of irri- 
gation starts with the preparation of the patient, the nurse and 
the apparatus. The entire vulva should be carefully cleansed, — 
first with soap and water, and then with a solution of bichloride 
of mercury. The nurse's hands should be scrubbed and then 
immersed in a solution of bichloride. The funnel, tube, joint 
and catheter, as well as the pitcher containing the solution, should 
be sterilized by boiling and the solution prepared from sterile 



154 MINOR TECHNIC IN SURGICAL NURSING 

water. The catheter is then inserted and such urine as may be 
in the bladder drawn off. The joint between the tube and cathe- 
ter is now connected, care being taken to see that the tube is 
filled with solution so as to prevent the introduction of air into 
the bladder. The funnel is filled with solution (being held at or 
below level of bladder) and the solution run into the bladder by 
raising the funnel to a height of several inches or a foot above 
the bladder. This process is repeated several times, until the 
patient complains of a sensation of fulness, when the process is 
reversed, — the funnel being lowered until it is filled by the return 
flow, which is emptied into the provided receptacle, and the 
process repeated until there is but one funnel-ful left in the 
bladder. The object of leaving some of the solution in the 
bladder is to prevent the already inflamed and tender bladder 
walls from collapsing and coming in contact with the catheter. 
This precaution requires the nurse to keep accurate count of 
the amount of solution that has been introduced, — an easy matter 
if the number of times that the funnel is filled be remembered. 
This filling and emptying of the bladder is repeated a number of 
times, — the number depending upon the condition present and 
the result desired. 

4. Vaginal Douche. — The vaginal treatments with which the 
nurse is most immediately concerned are the various solutions 
used for medicated douches. The effects of vaginal douches are 
remedial in three wa} r s: by the action of heat and cold; by their 
mere mechanical cleansing effect; and by the application of cura- 
tive solutions to the parts. Two or more of these objects may 
be combined by the giving of a warm douche of some antiseptic 
solution for the multiple purpose of obtaining the combined 
benefits of heat, cleansing and antisepsis. 

Tecknic. — The necessary articles are a glass or enamel douche 
can or rubber douche bag, a rubber tube and a glass vaginal 
douche nozzle for the administration of the douche. In addition, 
there should be the douche pan for the patient and the solutions 
and sponges for cleansing the external genitalia. The can, tube 
and tip should be sterilized by boiling. The solution should be 
prepared from sterile water. The preparation of the external 
genitalia should be as that for catheterization. And the prepara- 
tion of the nurse should be the same as for any other aseptic 
procedure. It is true that, in some cases, the strictest technic 
may seem somewhat out of place, but the habitual slighting of the 



REMEDIAL MEASURES 155 

proper technic in some of the less important cases will invariably 
lead up to a corresponding carelessness in the occasional case 
where the error will involve vital responsibility. The douche tip 
having been introduced under aseptic precautions, the can is 
raised until there is a free flow without excessive speed or force. 
The object of the douche is never to run a stream of solution as 
rapidly and forcefully as possible over the mucous surface of the 
vagina, but to bathe with a cleansing or curative application — 
and this fact should never be lost sight of in the demands of 
hospital work upon the time and efforts. 

5. Changing of Perineal Dressings After Vaginal or Perineal 
Operation. — The duty of keeping the perineal dressings fresh 
after a minor operation is generally, and indeed necessarily, left 
to the nurse. As it is necessary for the nurse to remove these 
dressings every time that the patient desires to urinate or to 
have an evacuation of the bowels, and to carefully cleanse the 
parts with an antiseptic solution before reapplying the dressings, 
it is only natural that the entire responsibility of caring for these 
dressings should be assigned to her. She should see, as above 
indicated, that the parts are carefully cleansed after passage of 
urinary or fecal matter. She should also see that the dressings 
are maintained in a fresh condition at all times and that they 
be not permitted to become so disarranged that the operative 
wound is exposed to infection or the patient's bedclothing to 
soiling with the discharges. The dressings are usually of the 
simplest character, consisting of specially constructed vulvar pads, 
sterile gauze fluffs, or any of the other usual forms of sterile 
dressings, kept in position by a T-binder. 

III. ASEPTIC WARD MEASURES, IN WHICH THE NURSE PRE- 
PARES AND ASSISTS 

In taking up this branch of gynaecological nursing, we shall 
endeavor to give the nurse an idea of just what will be required 
of her in the preparation for some of the more usual and important 
of the ward measures in which she participates as the assistant 
of the attending or resident physician. It is, of course, impossible 
to say in positive terms that there are certain things and none 
other that will be expected of her, as the custom must vary in 
different institutions and under different surgeons. The endeavor, 
therefore, will be to give a general outline that will enable the 
nurse to see what will be expected of her in the ordinary course 



156 MINOR TECHXIC IX SURGICAL NOISING 

of events and the instruments that are always necessary and gen- 
erally sufficient for the end in view. 

1. The Dressing Room. — A separate room for the dressing of 
wounds is a desirable but not essential adjunct to the ward. 
There may be a separate room for each ward, or one well-equipped 
room or suite of rooms may serve for several or even for all of 
the wards of the hospital. In the latter case a number of nurses 
will be assigned to special duty in the dressing room during 
certain hours of the day. usually in the morning. The dressing 
rooms should not be connected with the operating suite, since 
many of the cases to be dressed are suppurating and the presence 
of pus where aseptic operations are being done is to be avoided 
as far as possible. Clean cases are better dressed apart from 
septic ones, although with proper precautions the danger of a 
wound's becoming infected at a dressing is small. 

The equipment of the dressing room will be much like that 
of the operating room, but on a smaller scale. The fixtures will 
include basins with running water for hand scrubbing, apparatus 
for hot and cold sterile water and an instrument sterilizer. 
Sterile towels, gauze dressing materials and sponges in sterile 
packages will be supplied for the use of the wards from the 
operating room. The furniture, all of enamelled iron and glass, 
will include an operating table of simple pattern, one or two 
tables, a cabinet with shelves and drawers, two or three stools and 
chairs, an irrigating stand, a number of basins and trays of differ- 
ent sizes, and wheel stretchers for conveying patients. A folding 
screen like those used in the wards will be needed in some cases. 
The instrumental outfit required is very simple, but a sufficient 
number of each kind of instrument should be provided so that 
there may be no delay where several dressings are being done at 
the same time. Bandage scissors and at times a plaster knife 
or plaster shears will be needed. The standard sterile dressing 
set of instruments consists of two dressing forceps, one thumb 
forceps, one - >ne probe. An additional pair of sciss ra 

of a special pattern (Littauer's; designed for removing sutures 
is convenient. For minor gynaecologies vaginal speculum, 

uterine dressing forceps, and a vulsella should be added. The 
instrument cabinet may also contain space for all the instruments 
of the ward outfit which are described in other sections of this 
chapter. Rubber good- that may be required have already been 
enumerated. An abundant supply of sterile dressing materials 



REMEDIAL MEASURES 157 

in packages, bandages, binders, and adhesive plaster should be 
at hand. Standard solutions or tablets for making antiseptic 
solutions of any desired strength, alcohol, benzine, collodion, 
ether, hydrogen peroxide, balsam of Peru, bismuth paste, oxide 
of zinc ointment and such special formulae of dusting powders, 
ointments and other local applications as the practice in the 
institution calls for should be provided. 

2. The Dressing Cart. — There are always cases in the open 
wards that cannot be safely or conveniently moved to the dressing 
room, and private patients are usually dressed in their own rooms. 
For these cases some kind of a vehicle on wheels must be used to 
convey the instruments and materials required for a wound 
dressing to the bedside. 

Many forms of ward dressing carriages or carts are supplied 
by the manufacturers. There is little choice between them. The 
carriage should be on large rubber-tired wheels and should have 
plenty of shelf room for the materials to be conveyed. An irri- 
gating stand attached to the carriage is not a specially desirable 
addition. The carriage may be equipped either for a single 
dressing or for a number of dressings to be done in succession, 
and the arrangement of supplies will be somewhat different for 
these two purposes. Where several dressings are to be done one 
or two drums filled with dressing materials and sponges in sterile 
packages sufficient for all the cases will be provided, and enough 
dressing instruments to supply a fresh set for each individual 
case may be sterilized in bulk. An empty tray for soiled instru- 
ments, and basins or, better, paper bags for the soiled dressings 
will be needed, together with an abundant supply of bandages, 
adhesive straps and binders. A number of prepared wick drains, 
iodoform gauze in strips, and also uterine and vaginal gauze 
should be included in the equipment. Adhesive straps with 
tapes attached may be occasionally called for and several sets 
should be provided (Fig. 74) . Where a single case is to be dressed 
only one set of instruments and dressings will be required. Cer- 
tain stock supplies should be always on the carriage. These 
include protective (gutta-percha) tissue in strips, two by eight 
inches, immersed in bichloride solution in a wide-mouthed jar; 
benzine for loosening adhesive plaster; alcohol; tincture of iodine 
with alcohol (equal parts); a flask of sterile normal salt solution; 
peroxide of hydrogen; balsam of Peru; sterile vaseline; oxide of 
zinc ointment; boric acid ointment; pencils of fused silver nitrate 



158 MINOR TECHNIC IN SURGICAL NURSING 

(lunar caustic) and nitrate of silver in solution; scarlet red; talcum 
powder and special formula? of dusting powders; and one or two 
basins containing bichloride (1 to 3000) or other antiseptic 
solution. The last item may perhaps be regarded as a survival 
of the antiseptic era. In some of the best clinics all wounds are 
now dressed with dry sponges without the use of any antiseptic 
solutions whatever. Sponging the neighborhood of the wound 
with alcohol adds to the patient's comfort, and may be done for 
that reason. Hand disinfection and rubber gloves are unnecessary 
in the routine dressing of even clean wounds, the surgeon handling 
everything with sterile instruments. When, for any reason, it 
is desirable to touch the wound with the hands, rubber gloves 
will be worn whether the wound is clean or suppurating, in the 




Fig. 74. — Taped adhesive strips. 

former case to avoid wound infection and in the latter to protect 
the surgeon's hands from contamination with septic material. 
The various kinds of surgical cases that require more or less 
frequent change of dressings may be classified as follows: (1) 
Clean operative wounds in which the dressing put on at the time 
of the operation is allowed to remain undisturbed for from four 
days to two weeks, usually about ten days. In these only one 
or two redressings are usually necessary. (2) Accidental wounds 
which heal aseptically like operative wounds. (3) Suppurating 
wounds: these may be operative wounds, intended to be clean, 
which have become infected almost always through some fail- 
ure in carrying out the aseptic technic, or they may be cases 
in which the operation was originally done for a septic condition, 
such, for example, as a gangrenous appendix or an empyema, 
or they may be accidental wounds, infected either at the time of 



REMEDIAL MEASURES 159 

the accident or through careless handling later. In these drains 
will have been inserted and fresh drains may be required from 
time to time. (4) Suppurating sinuses resulting from infected 
operative or accidental wounds or from septic diseases in cases 
that have not been operated on. In some of these suppurating 
wounds and lesions the discharge of pus may be very great, 
necessitating daily dressings. (5) Fistulous openings communi- 
cating with the intestines or bladder: these are sometimes 
accidental and sometimes deliberately made by the surgeon. 
The faeces or the urine, as the case may be, will be constantly dis- 
charged through the wound and the dressings will have to be 
changed very frequently, sometimes several times in the day. 

(6) Ulcers, such as varicose ulcers of the leg, bed-sores, etc. 

(7) Burns and scalds, which may be superficial or deep, and 
always in the more severe cases require frequent attention. 

3. Dressing of Abdominal Wound. — As the first step in the 
dressing of an abdominal wound is the removal of the old dressing, 
and as the old dressing is generally held in place by adhesive 
straps, the first necessity is something for the removal of the 
adhesive plaster. Therefore, the first accompaniment of the 
dressing tray (or carriage) is a small bottle of benzine. This 
should be accompanied by sponges for its application. The next 
article is a pus basin, or other receptacle, for the old dressings 
and the sponges to be used in the present dressing. Next in 
order come the sterile instruments for the proper performance 
of the dressing and the removal of stitches. These are: a basin 
with bichloride solution; sterile sponges; two dressing forceps; 
one thumb forceps; one scissors. This list completes the instru- 
ments necessary for the ordinary dressings, but these are usually 
supplemented by the addition of a probe. As a large part of the 
importance of the dressing should be the welfare and comfort 
of the patient, the next step should consist in carefully going 
over the entire area that has been covered by the old dressing, 
with alcohol. A bottle of this medicament should, therefore, be 
found on every dressing carriage. Finally should come the sterile 
dressings and the adhesive plaster for fastening them in place. 
If an abdominal binder is used, a fresh one should be at hand 
for use at the completion of the dressing. As supplements, in 
the occasional case where slight infection or granulation is found 
at the first dressing, it is well to add a small bottle of balsam of 
Peru and a stick of silver nitrate to each dressing tray. 



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CHAPTER XI 
FRACTIONAL DOSES IN HYPODERMIC MEDICATION 

The problem of hypodermic medication seems, at times, to 
present a serious stumbling block to the nurse who, while per- 
fectly familiar with the technic of administration, is unused to 
dealing with those irregular doses that are not supplied in stock 
tablets, or, if so supplied, are not at hand. But the same person 
would probably feel affronted if asked if she had studied arith- 
metic through common fractions. Yet it is there that the solu- 
tion lies, and the method of partition is such an essentially 
simple one that there is no shadow of an excuse for the splitting 
of hypodermic tablets with a pin, a pen-knife, or a thumb nail. 
And, ridiculous as it may seem, no one of these latter procedures 
is uncommon. 

What, then, is the accurate and scientific method of obtaining 
the proper fractional dose of a stock tablet? We must follow 
it back to the process of obtaining the lowest common denomina- 
tor of two simple common fractions and then apply this knowl- 
edge to the division of a known quantity of solution. 

For example, suppose that we have a tablet containing X 2 of 
a grain of heroin hydrochloride and that a dose containing %6 of 
a grain is ordered. The fractions here are X2 and Ke- The lowest 
common denominator of the fractions is the least common 
multiple of their denominators. What is it in this case? The 
least common multiple of 12 and 16 is 48. Therefore, the lowest 
common denominator of X2 and jie is 48. Reducing, now, to frac- 
tions of a common denominator, X2 equals %& and }{& equals % 8 . 
Therefore, % 6 is % of X2. The further application is quite as simple 
as what has gone before. The average hypodermic syringe has 
a capacity of 25 minims. The tablet containing X2 of a grain is 
dissolved in this amount of sterile water and drawn into the 
syringe. We now have a 25-minim solution containing K2 of a 
grain of heroin hydrochloride. But, the dose ordered being 
only % of this amount or # 6 of a grain, % of 25 minims or 6% 
minims is expelled from the syringe and the remaining % or 18% 
minims injected hypodermically. It is immediately clear that 
11 161 



162 MINOR TECHNIC IN SURGICAL NURSING 

the division of one minim into quarters and the expulsion of 
one-quarter is not feasible. We have, therefore, evidently chosen 
an inconvenient quantity for making the solution. How, then, 
is this to be avoided? We will take a number of minims which 
is an exact multiple of the denominator of the fraction repre- 
senting the part of the total solution that is to be given. In 
this case the fraction is three-fourths. The denominator is 4. 
The highest number of minims in a total capacity of 25 that is 
exactly divisible by 4 is 24. W^e, therefore, use 24 minims. The 
result is now simplified. One-fourth of 24 is 6. We, therefore, 
eject 6 minims of the solution from the syringe and give the 
remaining 18. 

This is the general application of the method, the only varia- 
tion being in the total quantity of water used in the making up 
of the solution. If, for instance, a dose of % of a grain of mor- 
phine sulphate is ordered and the stock tablet at hand contains 
% of a grain, by the same process of lowest common multiples we 
find % of the stock tablet is to be given. We again use but 24 
minims in making the solution and expel 8 minims, this being 
for convenience, as there would be some difficulty in expelling 
an exact % of 25 minims. 

In the following table an effort has been made to give a list 
of the more common stock tablets, together with the fractional 
doses that may be ordered. The arrangement in such a table 
gives immediately the fraction of the stock tablet that must be 
taken to give the desired dose. This leaves only the amount 
of water in which it must be dissolved for determination by the 
nurse and may, consequently, be some saving in time and effort, 
particularly for the more difficult and unusual doses. 

In arranging the table, the vertical column of quantities 
represents the size of the stock tablet and the horizontal row 
of quantities the size of the dose ordered. To use the table in 
any given case, it is only necessary to select that quantity in the 
vertical column that corresponds with the size of the stock 
tablet at hand and follow it across the table in a horizontal line 
until the division corresponding to the size of the dose ordered 
is reached. The fraction found in this place will represent the 
part of the stock tablet to be used. If the dose ordered is larger 
than the stock tablet, the space will indicate the number of stock 
tablets to be used in making the solution and the fraction of 
this quantity that is to be used. 



FRACTIONAL DOSES IN HYPODERMIC MEDICATION 163 







gr. | 


gr. | gr. | 


gr. tV 


gr. ts 


gr. A 


gr. 3V 


gr. 4V 


gr. B 'o 


gr. TDU 


gr. tku 


gr. 1 


1 




1 
2 


1 


1 

4 


l 

6 


2 

15 


JL 
1 


.L 


2 


A 


gr. i 


|of2 


1 


3 

4 


1 

2 


I 


i 


* 


A 


1 
10 


o^O" 


A 


gr. 1 


2 


|of2 


1 


3 


i 


1 
3 


A 


* 


A 


2T 


j\ 


gr. tV 


3 


2 


|of2 


1 


3 
4 


~2 


1 


TO" 


1 


3 
25 


A 


gr- A 


4 


|of3 


2 


fof2 


1 


3 


T 8 5 


2 


_4_ 
1 5 


2\ 


T 8 5 


gr. & 




4 


3 


2 


|of2 


1 


£ 


5^ 


f 


2 6 5 


A 


gr. A 






l-fof4 


|of3 


Hof2 


fof2 


1 


3 
4 


, 
-% 


i 3 o 


1 


gr. 4V 








fof4 


|of3 


fof2 


fof2 


1 


f 


I 


A 


gr. A 










it of 4 


fof3 


2 


|of2 


1 


t 


2 
5 


gr- too 














fof4 


|of3 


|of2 


1 


2. 


gr- xio 






1 






5 


if of 4 


|of3 


|of2 


1 



In using the table, it is evident that another problem arises 
after the necessary fraction is obtained, in those doses that 
involve a very small proportion of the stock tablet to be used. 
Of course, these doses are quite unusual, being resorted to in 
those cases where an opiate is to be given to a child. It must be 
granted that, in the well-equipped hospital, it will seldom be 
necessary to resort to these fractional or multiple doses, but it 
is equally true that the simpler forms will not be unusual in 
private nursing, where the nurse has but one size of each tablet 
in her hypodermic case and this size may not correspond to the 
dose ordered. Applying the use of our table to the original 
problem of administering a dose of Yw of a grain when the stock 
tablet contains K2 of a grain, we find the process a very simple 
one. Taking the horizontal column representing the stock tablet 
of Yi2 of a grain and proceeding across to the vertical column 
representing % 6 of a grain, we obtain the required fraction of %. 
The stock tablet is then dissolved in 24 minims of sterile water, 
6 minims expelled and the remaining 18 minims injected. This, 



164 MINOR TECHXIC IX SURGICAL NURSING 

as we have said, is one of the simplest applications. But, taking 
one of the more unusual multiple doses, let us assume that the 
stock tablet contains }& of a grain and that the dose ordered is 
% of a grain. Here, taking the %o of a grain horizontal column and 
carrying it across to the %> of a grain vertical column, we find the 
required close to be % of 3 tablets. As % of 25 minims would be 
rather difficult to measure, we must first decide upon the quantity 
of sterile water to take into the syringe. We decide upon 24 
minims because it is the largest quantity that can be contained 
in the syringe and of which % can be easily obtained, % equalling 
%. Three stock tablets are then dissolved in 24 minims of sterile 
water and drawn into the syringe. Four minims are expelled 
and the remaining 20 minims injected. This proceeding, while 
somewhat more complicated than the first, is still quite simple. 
The third example taken will be one of the most difficult forms, 
and, at the same time (fortunately), one of the most infrequent. 
We shall assume that a dose of % 5 o of a grain of morphine sulphate 
has been ordered for a child and that the only available tablet 
contains } A of a grain. Reference to the table gives us the required 
fraction as 775. It is immediately evident that it will be very 
difficult to accurately determine 2 :b of 25 minims in such a way 
as to be of any practical value in administering a hypodermic 
injection, the resulting fraction being % of a minim. What, then, 
are we to do? We must dissolve the tablet in a quantity of 
water that will enable us to easily obtain 775 of its total volume and 
of which 2 75 will make a quantity practicable for hypodermic 
injection. Here we are once more confronted with the problem 
of common multiples. We are to obtain the least common mul- 
tiple of 25 and 75. This is 75. But the use of 75 minims would 
still leave our dose 2 minims, which is much too small for hypo- 
dermic administration. We must, therefore, so increase the size 
of the remaining dose that its administration is feasible. Eight 
minims could be readily administered. 8 is 4 times 2. Therefore, 
an original total quantity of 4 times 75 (or 300) would give us an 
ultimate dose of practical size. So we take 300 minims of water, 
which is 5v, and dissolve in this quantity the K-grain tablet. 
2 75 of 300 equals 8. We, therefore, inject 8 minims of the total 
solution, thus giving the required close of }4o of a grain. A hypo- 
dermic injection of 8 minims is quite practicable, but the quantity 
might have been three or four minims, an impracticable dose. In 
such a case, the difficulty may be overcome in either of two ways: 



FRACTIONAL DOSES IN HYPODERMIC MEDICATION 165 

(1) the small dose may be taken and increased by the addition 
of sufficient sterile water to make up a suitable quantity; or, (2) 
the original quantity of water represented in minims by the 
size of the least common multiple may be doubled or tripled 
before the solution is made and the quantity of the final solution 
to be administered thus increased. 

It will be noted that some twenty doses have been omitted at 
the lower left-hand corner of the table. This has been done with 
the idea of keeping the multiple doses, so far as possible, within 
practical limits. The omitted doses all deal with quantities of 
five tablets or more, some being more than twenty-five. As it 
can scarcely be conceived that any dose will be ordered that 
would require the dissolving of so many tablets or that such a 
number would be at hand should the dose be ordered, it has 
seemed as well to omit the doses of this kind from tabulation. 

General Rules. — 1. Reduce the fractions representing the 
size of the dose and the size of the stock tablet, at hand, to 
fractions with a common denominator. A new fraction, whose 
numerator is the numerator of the fraction representing the dose 
and whose denominator is the numerator of the fraction represent- 
ing the tablet, gives the fraction of the stock tablet to be taken. 
The stock tablet is dissolved in the greatest number of minims of 
water containable in the syringe and evenly divisible by the denom- 
inator of the new fraction. This solution is drawn into the syringe 
and that part of it, equal to the new fraction, administered to 
the patient, the remainder being first ejected from the syringe. 

2. Where the new fraction (obtained as above) is greater than 
one (as %) , a number of stock tablets is taken, equal to the whole 
number next larger than the new fraction (in this case 2 tablets) . 
A second fraction, obtained by multiplying the denominator of 
the new fraction by the number of tablets used, gives the part 
of the total solution to be used (here %) . 

3. Where the new fraction (obtained as in the general rule 1) 
is so small as to leave an amount impractical for administration, 
the amount used for making the solution must be increased as 
many times over the number of minims divisible by the denomi- 
nator of the new fraction as the part of that sum represented by the 
new fraction must be increased to give a dose of practical size. 

Example. — Suppose the new fraction to be %&• This would 
make the dose to be administered only one minim, if a single 
syringef ul (25 minims) were used in making the solution. Suppose 



166 MINOR TECHNIC IN SURGICAL NURSING 

that we decide upon 10 minims as the size of the minimum practi- 
cal hypodermic dose. Then, according to the rule given above, 
instead of using one syringeful to make the solution, we use ten, 
and, instead of giving one drop of this solution, we give ten drops. 
Stock Tablets. — As an indication of the forms in which some 
of the more common drugs used in surgery and gynaecology by 
the hypodermic method may be found, we shall enumerate the 
sizes of some of the more common stock tablets and the drugs 
occurring in doses of these sizes. 

Morphine sulphate: gr. %; gr. %; gr. )i. 
Heroin hydrochloride: gr. %; gr. %\ gr. Yu. 
Strychnine sulphate: gr. % ; gr. Xo. 
Physostigmine (eserine) salicylate: gr. Xo. 
Nitroglycerin : gr . Xoo . 
Atropine sulphate: gr. Xoo; gr. Xso. 

Examples. — 1. To give a dose of % of a grain when the stock 
tablet is % of a grain. 

9 | 6 4 

32 2X3X2 = 12 

Therefore, 12 is the least common multiple of 4 and 6, and the 
lowest common denominator of % and %. 

Therefore, % of a grain is % of X of a grain. 

The highest number of minims in 25 (the maximum contents 
of the syringe), equally divisible by 3 (the denominator of the 
new fraction, %), is 24. We, therefore, dissolve the tablet contain- 
ing % of a grain in 24 minims of sterile water and draw into the 
syringe. But, as only % of this quantity is to be administered, we first 
eject % (8 minims) and administer the remainder (16 minims). 

2. To give a dose of % of a grain, when the stock tablet is 
% of a grain. We proceed, as before, to obtain the lowest com- 
mon denominator of )i and %. 

2l 8, 4 

2l 4,2 2X2X2X1=8 

2, 1 

Therefore, )i of a grain is % of % of a grain. 

The highest number of minims in 25, exactly divisible by 
2, is 24. We, therefore, dissolve the tablet containing % of a 
grain in 24 minims of water and draw this into the syringe. But, 



FRACTIONAL DOSES IN HYPODERMIC MEDICATION 167 

as only % of this is to be administered, we first eject ji (12 minims) 
and administer the remainder (12 minims). 

3. To give a dose of % of a grain, when the stock tablet is 
% of a grain. Finding the least common denominator of % and %: 

2l 6, 8 



3,4 



2X3X4=24 



Therefore, % is % of %. 

The highest number of minims in 25, exactly divisible by 4, 
is 24. We, therefore, dissolve the tablet containing % of a grain 
in 24 minims of sterile water. As only % of this is to be adminis- 
tered, we eject % (6 minims) from the syringe and administer 
the remaining % (18 minims). 

4. To give Yn of a grain, when the stock tablet contains % of 
a grain. Finding the least common denominator of K2 and )i: 

2 1 12, 8 

2 l 6,4 2X2X3X2 = 24 

3 2 

Therefore, K2 is % of %. 

Twenty-four minims being the largest sum exactly divisible 
by 24, we dissolve the tablet of % of a grain in 24 minims, eject 
% (8 minims) and give the remaining % (16 minims). 

To show the application of the general rules, we shall take 
example 1: 

The least common denominator has been found to be 12 and 
the fractions transposed, % equalling % 2 and ]i equalling % 2 . By 
rule 1, the new fraction is obtained by taking the numerator of the 
dose as a new numerator and the numerator of the tablet as a new 
denominator. The dose is K2 and %. the tablet. Therefore, 2 is the 
numerator and 3 is the denominator, the new fraction being %. 
This is the new fraction of the tablet to be given. This tablet is 
dissolved in 24 minims of water. The solution is drawn into the 
syringe and that part of it equal to the new fraction administered. 

5. To give a dose of % of a grain when the stock tablet is }i of 
a grain. Finding the least common denominator of % and % : 

9.\ 6,8 



Reducing: 
Therefore, % is % of %. 



3, 4 



2X3X4=24 



168 MINOR TECHNIC IN SURGICAL NURSING 

Hence, as % is greater than one tablet and less than two tablets, 
we must use two tablets in our solution. Two tablets of )i of a 
grain equals % of a grain, or % 4 of a grain. 

If % = /24 and % = %a, then % is% (or %) of %. We, then, dissolve the 
two tablets containing each l /% of a grain in 24 minims of sterile 
water (the greatest part of 25 minims exactly divisible by 3) and, 
after ejecting % or 8 minims, administer the remaining 16 minims. 

Applying general rule 2 in the above, we multiply the de- 
nominator of the new fraction (%) by the number of tablets used 
(2) and get a second fraction, %. This corresponds wdth the result 
obtained above. 

6. To give a dose of % of a grain, when the stock tablet is %2 of 
a grain. Finding the least common denominator of %o and &: 
2! 60, 12 

2 ! *°' I 2X2X3X5X1=60 

31 15, 3 

5, 1 

Reducing: y 60 =% &=%> 

Therefore, %o is % of &. 25 is exactly divisible by 5, therefore 
25 minims is the quantity taken for the solution. % of this is 
to be administered. % of 25 is 5, a quantity rather small for hypo- 
dermic administration. But 15 minims is readily administered. 
This amount is three times 5. Therefore, 75 minims (or 3 syringe- 
fuls, or 3 times 25 minims) is taken to make the solution and 
15 minims of this drawn into the syringe and administered. 

6. To give a dose of Xso of a grain, when the stock tablet is }{ of 
a grain. Finding the least common denominator of Xso and%: 

2 l f:t 2X75X2=300 

75, I 

Reducing : y lb0 = * m \ . = - 300 

Therefore, Km is %5 of %. 25 minims (the maximum contents of 
the syringe) is not equally divisible by 75, the denominator of 
the new fraction, but 75 (or three times this amount) is just 
divisible. Therefore, if the solution is made in three syringefuls 
(or 75 minims) of water, two minims of this solution would be 
the desired dose. But a hypodermic dose of two minims is not 
practical. Twelve minims is, however, practical; 12 is 6 times 2, 
the original dose. Therefore, a quantity of water equal to 6 times 
75 (450 minims, or VA drachms) is used in making the solution 
and 12 minims of this drawn into the syringe and administered. 



CHAPTER XII 

WEIGHTS, MEASURES, SOLUTIONS AND FORMULA 
I. WEIGHTS AND MEASURES 

Although it may be presupposed that the nurses who are 
studying the surgical and gynaecological part of their course 
have already mastered the subject of weights and measures, in 
its various applications, yet it appears wise to reconsider it in 
this place, particularly in connection with its application to the 
preparation of solutions. 

There are two systems now in common use for the measuring 
of distance, weight and volume. These are the English and the 
metric systems. The former is a fairly independent and unrelated 
series of tables, each with its distinct unit, which is increased by 
arbitrary multiples to obtain the next higher unit. In the metric 
system, however, the linear unit is the basis, not alone for the 
measure of distance, but also of weight and volume, and the 
graduation of succeeding greater units is based upon the decimal 
system, each being ten times greater than the next smaller. Such 
a system is obviously more scientific and, indeed, more simple 
than the English system, but long usage has made the latter so 
much a part of our customs that it is difficult to have it discarded, 
even for a better. 

A. Linear Measure. — The English system of linear measure 
is, of course, familiar to all and is given here merely for the pur- 
pose of comparison with the metric linear measure. 

12 inches equal 1 foot 

3 feet equal 1 yard 

5H yards equal 1 rod (or perch) 

40 rods equal 1 furlong 

8 furlongs equal 1 mile 

The entire metric system, as already stated, is based upon the 
linear unit (the metre) , which is equal to one ten-millionth of a 
quarter meridian of the earth, or about 39.37 English inches. 
This linear unit being assumed, those of successive higher order 
are obtained in multiples of ten (represented by Greek prefixes) 
and those of successive lower order by decimal fractions (repre- 
sented by Latin prefixes). Thus (where, in the English system, 

169 



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m-'ii .i" I" • -ne: «. mm m: j? mml, " i "M»e j-"'h-t" : 
-. >":i:iM' a ;- "iii-— "mm »: i iiiTTrr*T .' "M "m~mm'-- 

I 



WEIGHTS, MEASURES, SOLUTIONS AND FORMULAE 171 

larger units of volume are obtained identically as in the linear 
system, by the use of Greek prefixes to denote successive multiples 
of ten of the standard unit and the smaller units by the use of 
Latin prefixes to denote successive decimal fractions. Thus: 

10 litres equal 1 decalitre 

100 litres equal 10 decalitres equal 1 hectolitre (HI.) 

1000 litres equal 100 decalitres equal 10 hectolitres equal 1 kilolitre (Kl.) 

On a descending scale, we have: 

1 litre (L.) . .equals 10 decilitres (dl.) . .equal 100 centilitres (cl.) . .equal 1000 millilitres (ml.) 

To this brief summary may be added that the cubic centimetre, 
with its multiples and decimal fractions, is usually employed as 
the unit of volume in medical work and is equivalent to a trifle 
over ntxvi. The litre measures somewhat over a quart (about 
1.05 quarts). 

C. Measures of Weight. — In the English system, the unit of 
weight is the grain (abbreviated gr.) and we have the following 
table : 

20 grains (gr. xx) equal 1 scruple ( 3 i) 

3 scruples ( 3 iii) equal 1 drachm ( 5 i) 

8 drachms ( 3 viii) equal 1 ounce ( 3 i) 

12 ounces ( 5 xii) equal 1 pound (Ibi) 

The unit of weight in the metric system is the gramme, which 
represents the weight of one cubic centimetre of pure water — 
thus, again, going back to the linear system for its unit. And, 
again, we have the identical system of construction for the 
table. Thus: 

10 grammes equal 1 decagramme (Dg.) 
100 grammes equal 10 decagrammes equal 1 hectogramme (Hg.) 
1000 grammes equal 100 decagrammes equal 10 hectogrammes equal 1 kilogramme (Kg.) 

and, further, 

1 gramme (Gm.) . . . equals 10 decigrammes (dg.) . . . equal 100 centigrammes (eg.) . . . equal 
1000 milligrammes (mg.) 

The gramme is equal to about gr. xv in the apothecaries' system. 
Although, from what has here been said, we may gather some 
idea of the greater simplicity of the metric over the English 
system of weights and measures, yet no true appreciation of the 
enormous difference can exist until we consider that only one of 
the English tables of weight and one of the tables of volume have 
been considered (the apothecaries' in each case). When we realize 
that there are, in addition to these, the avoirdupois and troy 
systems for weights and the imperial, cubic and dry measures 



172 MINOR TECHNIC IN SURGICAL NURSING 

for volume, then alone can the great advantage accruing from the 
general adoption of such a system as the metric be appreciated. 

Transposition of Tables. — After the somewhat extended 
attention given to prefatory considerations, we shall endeavor 
to even further simplify their application. The tables of linear 
measure will be disregarded as of no particular interest to the 
nurse, and the measures of volume and weight will be considered 
as possessed of only one unit each, — the cubic centimetre and 
the gramme. We have already stated that the cubic centimetre 
equals about 16 minims and the gramme about 15 grains. We 
have, further, stated that practically all prescriptions employing 
the metric system are written in decimal multiples or fractions 
of these units. The system of writing, therefore, is identical to 
that employed in our monetary system, — the unit being the 
cubic centimetre or the gramme instead of the dollar. Thus, it 
should be quite as simple to read Gm. 3.25 as $3.25, — one repre- 
senting three and twenty-five one-hundredths dollars and the 
other three and twenty-five one-hundredths grammes. 

The transposition from one sj^stem to the other should be 
equally simple. Taking the above example, suppose that we 
wish to transpose Gm. 3.25 to its equivalent in the apothecaries' 
system of weights. 

We know that Gm. 1 equals gr. xv 

Therefore Gm. 3.25 equals 15 X 3.25 equals 4S.75 grains 

Thus, Gm. 3.25 equal gr. 48% 

The reverse process is equally simple. Suppose, for instance, 
that we wish to transpose fgiiss (2}A) from the apothecaries' to 
the metric system. 

(1) There are 480 minims in an ounce. 

(2) Therefore 2V 2 ounces equal 2.5 X 480 or 1200 minims. 

(3) 16 minims equal 1 cubic centimetre. 

(4) Therefore 1200 divided by 16 (i.e., 75) equals the number of cubic centimetres in f * iiss 

(5) Thus, f3iiss=75 c.c. 

From these two examples, we promptly realize the simplicity 
of the application of the following general rule: To change 
quantities from the metric to the apothecaries' system, multiply 
(if liquid and expressed in cubic centimetres) by 16, to reduce to 
minims, and (if solid and expressed in grammes) by 15 to reduce 
to grains. To change from the apothecaries' to the metric, first 
reduce to grains (or minims) and then divide by 15 (if solid) to 
transpose to grammes, or by 16 (if liquid) to transpose to cubic 
centimetres. 



WEIGHTS, MEASURES, SOLUTIONS AND FORMULA 173 

II. SOLUTIONS 

Since such a large part of the surgical nurse's work consists 
in the preparation of solutions of drugs, it seems advisable that 
something more than passing notice should be devoted to this 
subject. The nurse is required to prepare physiological salt 
solution for dressings, or for subcutaneous, intravenous or rectal 
administration; various antiseptic solutions for use as a part of 
the aseptic technic or for wound dressings; solutions for enemata; 
solutions for vaginal douches; and other solutions for any one, 
or all, of the various fields covered by surgical nursing. In some 
instances, the amounts of the various constituents will be given. 
In others only the percentage strength of the solution will be 
specified, and, possibly, the total quantity of the solution to be 
used. It is in the latter class of cases, particularly, that the 
nurse must be familiar with the preparation of percentage 
solutions. 

The method of preparation of these solutions naturally divides 
itself into two parts, dependent upon which system of weights 
and measures is employed, — the metric or the apothecaries'. 
The natural tendency, in approaching this subject, is to mention 
the apothecaries' system only to condemn its use. However, 
the realization that custom has made the apothecaries' system 
the routine in many hospitals makes it necessary that we should 
give it due consideration. 

To make an aqueous solution (and this is the form generally 
prepared by the nurse) of any drug, it is first necessary to decide 
how much of the drug must be used, in order to make the desired 
percentage in the total quantity. The simplest method of accom- 
plishing this is by resolving the volume representing the total 
solution into its smallest units, which will be susceptible of treat- 
ment by the percentage system. For example, suppose that we 
are required to make up two gallons of a one-half per cent, solu- 
tion of lysol. This looks like a rather imposing task. But, by 
reducing to its simplest form, we have 

2 gallons equal 8 quarts equal 16 pints equal 256 ounces equal 122,880 minims 

1 per cent, of 122,880 is 1228.80 
Y 2 of this is 614.40 

We, therefore, to 614 minims of lysol add enough water to make 

2 gallons. If it is inconvenient to measure 614 minims, we may 
first transpose it to higher units by the process of division, 
remembering that 60 minims equal 1 drachm and that 8 drachms 



174 MINOR TECHXIC IX SURGICAL NURSING 

equal 1 ounce, or that 480 minims equal one ounce. Thus, 
dividing 614 minims by 60. we find the equivalent quantity of 
5x TTpdv, and. further transposing 5x, we find the equivalent 
quanthy of 5i 5h\ Therefore, 614 minims equal 1 ounce, two 
drachms. 14 minims. 

This example, which shows the method employed to find the 
amount of a liquid drug that must be used to make up a specified 
quantity of a certain percentage, is identical with that used for 
solids, the latter being measured in grains instead of nrinims. 

In the use of the metric system, practically all of this work 
is unnecessary. Suppose that we take the same example. In 
the first place, it is necessary to transpose the 2 gallons to the 
metric system. The quantity being so large, absolute exactness 
may be to some extent disregarded. We know that one quart 
equals approximately one litre. Therefore. 2 gallons, equalling 
8 quarts, also equal 8 litres. We. now. have the problem of 
making 8 litres of a ^4 per cent, lysol solution. 

1 litre equals 1000 cubic centimetres 

S litres equal S000 cubic centimetres 

1 per cent, (or one one-hundredth) of S000 is 80.00 

y 2 of SO. 00 is 40.00 

We. therefore, add to 40 cubic centimetres of lysol sufficient 
water to make 8 litres. The only inaccuracy in this solution is 
that, by transposing to the metric system, we have made up 
slightly more than the required quantity of the solution, but of 
exactly the required percentage. 

III. FORMULJE 

In every hospital there are in general use a number of stock 
solutions or preparations for various purposes. These may be 
in the form of tablets of a given strength, from which the diluted 
solutions are prepared, or they may be in the form of solutions 
of varying degrees of concentration, which are used either as 
prepared or after considerable dilution. While it would, of course, 
be quite out of the question to give even an approximately full 
list of these preparations in this place, yet a few of the more 
common and. possibly, more important will be tabulated. In 
addition, there will be included some formulae which may not 
be kept prepared but which appear of sufficient importance to 
warrant their presence in such an abbreviated list. 



WEIGHTS, MEASURES, SOLUTIONS AND FORMULA 175 

Formulae for local anaesthesia: 

1. Cocaine and adrenalin (A): 

Cocaine hydrochloride 0.03 gm. 

Adrenalin chloride 0.003 gm. 

Sodium chloride 0.18 gm. 

Distilled water 30.00 c.c. 

This makes a solution of cocaine (1-1000) and adrenalin (1-10,000) 
in physiological salt solution. 

2. Cocaine and adrenalin (B) : 

Cocaine hydrochloride 0.3 gm. 

Adrenalin chloride 0.03 gm. 

Sodium chloride 0.18 gm. 

Distilled water. 30.00 c.c. 

This makes a solution of cocaine (1-100) and adrenalin 

(1-1000) in physiological salt solution. 
A simpler method of making these solutions is to use tablets 

already prepared in suitable strength, dissolving one in 

the proper quantity of physiological salt solution. 

3. Novocaine 1-400: 

Fill flasks with distilled water and add salt to make normal 
saline. Boil twenty minutes. Add novocaine crystals 
and boil two successive days, ten minutes each. 

4. Quinine and urea hydrochloride 1-200 : 

Fill flask with distilled water and boil twenty minutes. 
When cool, add sterile quinine and urea hydrochloride 
tablets. Boil ten minutes. Quinine and urea do not 
stand boiling as well as novocaine. 

The above formulae (3 and 4) are those used by Dr. Crile in 
his anoci-association work. 

Formulae for antiseptic solutions: 

1. Bichloride of mercury: 

Bichloride of mercury 1.00 gm. 

Water 1000.00 c.c. 

This makes a 1-1000 solution and may be used for preparing 
the surgeon's hands, the field of operation, etc. 

2. Harrington's solution: 

Commercial alcohol (94 per cent.) 640.00 c.c. 

Hydrochloric acid 60.00 c.c. 

Water 300.00 c.c. 

Bichloride of mercury 0.80 gm. 

Used for surgeon's hands, field of operation, etc. 

3. Iodine and alcohol: 

Tincture of iodine 50.00 c.c. 

Alcohol • 50.00 c.c. 



176 MINOR TECHNIC IN SURGICAL NURSING 

Formulae for enemata: 

1. 1-2-3 enema: 

Magnesium sulphate § i 

Glycerine 5ii 

Water §iii 

2. 2-4-S enema: 

Magnesium sulphate §ii 

Glycerine 5 iv 

Water gvih 

3. Oil and glycerine enema: 

Glycerine 30.00 c.c. 

Olive oil 90.00 c.c. 

Soapsuds 120.00 c.c. 

4. Oxgall and glycerine enema: 

OxgaU 8.00 c.c. 

Glycerine 120.00 c.c. 

Warm water 500.00 c.c. 

Formulae for saline solutions: 

1. Phj-siological salt solution: 

Sodium chloride 9.00 gm. 

Distilled water to 1000.00 c.c. 

2. Ringer's solution: 

Sodium chloride 9.00 gm. 

Potassium chloride 0.20 gm. 

Sodium bicarbonate 0.20 gm. 

Distilled water to 1000.00 c.c. 

3. Locke's solution: 

Calcium chloride 0.24 gm 

Potassium chloride 0.25 gm 

Sodium bicarbonate 0.20 gm 

Sodium chloride 9.00 gm 

Glucose 1 .00 gm 

Distilled water to 1000.00 c.c. 

4. Adler's solution: 

Sodium chloride 0.5900 gm 

Potassium chloride 0.0400 gm 

Calcium chloride 0.0400 gm 

Magnesium chloride 0.0250 gm 

Sodium phosphate 0.0126 gm 

Sodium bicarbonate 0.3510 gm 

Glucose 0.1500 gm 

Distilled water 9S.7914 c.c. 

These four formulae represent solutions used by hypoder- 
moclysis or intravenous infusion. The first is the usual solution 
and the other three are examples of attempts to more closely 
approximate the true blood-serum. 



WEIGHTS, MEASURES, SOLUTIONS AND FORMULA 177 

Formulae for ointments and pastes: 

1. Zinc oxide ointment: 

Zinc oxide 20.00 gm. 

Benzoinated lard 80.00 gm. 

2. Unna's paste: 

Gelatine 4 parts 

Water 10 parts 

Glycerine 10 parts 

Zinc oxide 4 parts 

3. Boracic acid ointment: 

Boracic acid 10.00 gm. 

Paraffin 10.00 gm. 

White vaseline 80.00 gm. 

4. Bismuth paste : 

Bismuth subnitrate 30.00 gm. 

White wax 5.00 gm. 

Soft paraffin 5.00 gm. 

Yellow vaseline 60.00 gm. 

5. Stearin paste: 

Melted stearin 50.00 c.c. 

Ammonia water 2000.00 c.c. 

Water 2000.00 c.c. 

6. Wax paste: 

Melted yellow wax 100.00 c.c. 

Ammonia water 300.00 c.c. 

Water 300.00 c.c. 

7. Marble dust (Schleich's) soap: 

Cut resin soap 750.00 gm. 

Warm water 1500.00 c.c. 

Melt and boil V/^ hours. Add 

Wax paste 150.00 gm. 

Stearin paste 150.00 gm. 

Marble dust 7000.00 gm. (15 lb.) 

Stir while boiling. 

Formulae for vaginal douches: 

1. Lysol 10.00 c.c. 

Water to make 2000.00 c.c. 

2. Alum acetate 8.00 gm. 

Water 2000.00 c.c. 

3. Bichloride of mercury 1.00 gm. 

Water 2000.00 c.c. 

4. Potassium permanganate 2.00 gm. 

Water 2000.00 c.c. 

12 



178 MIXOR TECHXIC IX SURGICAL XURSIXG 

Formula for Boudet's depilatory powder: 

Fresh unslaked lime 10.00 gm. 

Sodium sulphide cn^stals 3.00 gm. 

Powdered starch 10.00 gm. 

Rub into thick paste with water and apply about y± inch 
thick. Wash off after five minutes. 

The formulae and solutions already considered deal entirely 
with the handling of the actual medicament in its full strength. 
But another problem presents itself when, instead of the pure 
drug, a more or less concentrated solution thereof is the prepara- 
tion to be used. As examples of these concentrated solutions, 
we have the 10 per cent, aqueous solution of bichloride of mercury 
and the 10 per cent, aqueous solution of sodium chloride which 
are the stock strengths in many operating rooms from which 
weaker solutions of these drugs are prepared. And, naturally, 
the use of such a solution somewhat complicates the problem 
of finding the amount to be finally used. If a 1-3000 solution 
of bichloride of mercury is to be prepared from the pure drug, 
it is xevy easy to see that there must be one part of the drug to 
every 3000 parts of the final solution, or one gramme of the drug 
in even' 3000 c.c. of the solution. But. with a 10 per cent, solu- 
tion as a starting point, the problem does not end at this point. 
We have only found how much of a 100 per cent, concentration 
of the drug must be used. But we do know that 10 per cent, is 
only to of 100 per cent. Therefore, ten times as much of a 10 per 
cent, solution must be used as of the pure drug. In other words, 
instead of 1 part in each 3000, we must use 10 parts in each 3000. 
That is, we use 10 c.c. of the 10 per cent, solution in each 3000 
c.c. of the 1-3000 solution. In approaching the salt solution 
problem of preparing a to" per cent, solution from a 10 per cent., 
we employ the same method. If the preparation were 100 per 
cent, strength, we should have to use 9 parts of the preparation 
in each 1000 parts of the solution (as to per cent, equals t% of 
tt>tj, or two). But a 10 per cent, solution is only to as strong as a 
100 per cent, preparation and, therefore, 10 times as much must 
be used. Therefore, 90 parts of the 10 per cent, strength must be 
used in each 1000 parts of the solution. But 90 parts to the 1000 
equals 9 parts to the 100. Therefore, 9 c.c. of the 10 per cent, 
strength must be used in each 100 c.c. of the solution. 

The preparation of solutions of carbolic acid from the stock 
strength of 5 per cent, is, of course, identical in principle with 



WEIGHTS, MEASURES, SOLUTIONS AND FORMULAE 179 

the preceding examples. Suppose that a 3 per cent, solution of 
carbolic acid is required. Using the pure drug, this would require 
3 parts of the pure drug in each 100 parts of the solution. But 
a 5 per cent, solution is only two as strong as the pure drug. So 
we must use x ip- (i.e., 20) times as much of the 5 per cent, solution 
as of the pure drug. That is to say, we must use 60 parts of the 
5 per cent, strength to each 100 parts of the solution. 

A study of these three examples gives us the three steps 
followed in preparing solutions from other solutions of greater 
strength. (1) Find what part of the required solution the pure 
drug would represent. (2) Multiply this by the denominator of 
the fraction that represents the strength of the stock solution. 
(3) Divide this result by the numerator of the same fraction. 
The last step will be unnecessary when the numerator is 1. The 
amount thus obtained is then measured and to it is added enough 
of the solvent (usually water) to give the total quantity of solution 
required. 



CHAPTER XIII 

CHARTS AXD RECORDS 

I. THE CHART 

The proper keeping of the chart giving full details of the 
patient's condition, of what has been done and is being done for 
her. and the entire history of the patient from the beginnii:_ : 
her illness is one of the most exacting ■:: :he duties that fall to 
the share of the nurse. — either in hospital work or in private 
practice. The hospital chart is generally much fuller than that 
used in private nursing. — and, as a result, requires more attention. 
A full chart consists of a number of sheets for different purp: ises, 
mounted on a board with a clip for holding the sheets in place. 
These sheets are arranged according to a definite system in differ- 
ent hospitals, and may, indeed, be different in character and 
requirements. As a basis for description, a full chart that covers 
the entire field of diagnosis, treatment and daily progress will 
be considered at this time. While some of the sheets mentioned 
will be such as to be omitted in some charts, yet the entire number 
will be necessary in every case of operative character in which 
a full history has been taken and a thorough examination, 
both physical and pathological, made. The arrangement of the 
sheets for reference will be used, as this is the form of practical 
importance to the nurse rather than the order in which they are 
filed away among the hospital records. 

1. Cover Sheet. — This is generally a blank piece of white 
paper, upon which the name of the patient, date of admittance, 
ward and name of attending physician are to be written. It is 

merely as a cover for the remainder of the chart, with the 
double purpose of protecting the next page and preventing any 
one from seeing the other data without taking the chart for 
examination. 

2. Temperature Sheet. — This sheet has a space at the top 
\e for the patients name and the date and is so divided off 

into spaces that a record of the patient's temperature, pulse and 
ration may be kept upon it. as well as a summary as to the 
■tion of her bowels and kidneys. The temperature 

recorded on this sheet in the average case, is generally merely 
180 



CHARTS AND RECORDS 



181 



the morning and evening record 
(Fig. 75). It may, however, be 
divided into spaces with red 
ink lines so as to be used for 
every four-hour recording (Fig. 
76). This sheet gives to the 
physician, at one glance, a pic- 
ture of the patient's tempera- 
ture and pulse record from the 
time of her admittance to the 
hospital. 

3. Record Sheet. — This sheet 
has at its top space for the 
name of the patient and the 
date. Its contents are more 
comprehensive and minute than 
those of the temperature sheet. 
It is divided vertically into a 
number of columns, each with 
a heading to indicate the kind 
of information that is to be re- 
corded in that particular place 
(Fig. 77). Through each 24 
hours, as nourishment is given, 
or medicine administered; as the 
bowels or bladder act; as the 
temperature rises or falls, the 
time and all other details are 
recorded in the proper columns 
on this sheet. The temperature, 
pulse and respiration are gener- 
ally taken every four hours 
when using this sheet, although, 
in very serious cases, a two-hour 
temperature record maybe kept. 
As will be readily understood, a 
sheet of this kind has much 
data that would not be required 
in the simplest cases. It is, 
therefore, used only in opera- 




Fig. 75. — Chart showing morning and even- 
ing temperature. (Septic peritonitis.) 



isa 



MINOR TEOTSIC IX SURGICAL NTJRSEN 



^£ SG_ 



' £ y z - z ;» £ i" .r rti-c p> e. p- <i n,; r -: r £ r -z-^z r'<£ '"re 




tive cases and those where there is an elevation of temperature 
that requires watching. At the end of 2i hours, the material 



CHARTS AND RECORDS 



183 



gathered on the record sheet is totaled so as to give in a brief 
summary those facts of importance during the time covered. 

It is well that we should remark at this time upon one or two 
points of special interest and importance in the recording of data. 
The two points upon which particular emphasis will be placed 
are the recording of bowel and bladder evacuations. The first 
of these is particularly important in those cases where there 
seems the possibility of intestinal obstruction, and the patient 



Date Sheet No. 



Name. 



Date 


Hour 


Nourishment 


Medication 


Remarks 


Def. 


Urine 


7/7/15. 


8.30 




Morphine sulph. gr. }i\ On leaving for 












Atropine sul 


ph. gr.Xsoj operat ing room 








10.30 






Returned from O. R. 
Pulse good. 








11.20 






Fully reacted. 








1.00 


Water §i- 




Retained. 








8.00 






Voided. 




oviii 




8.00 






Complains of slight pain 
in region of incision. 








10.00 


Crushed ice. 




Voided. 




oiv 




12.00 






Sleeping. 






7/8/15. 


2.00 
4.00 
6.00 


Water ad lib. 




Voided. 

Turned p. r. n. 
Comfortable night. 




oix 




Twenty-four-hour summary. 








Water ad lib. 


Morphine sulph. gr. %\ On leaving for 
Atropine sulph. gr. KsoJ operating room 










Crushed ice. 














Voided. 




oxxi 










Turned p. r. n. 














Comfortable night. 







Fig. 77. 



-Type of record sheet. The more usual form has column for recording tempera- 
ture, pulse, and respiration. 



should be carefully watched during such times to decide whether 
or not gas is passed. Of course, this caution applies particularly 
after the administration of an enema, as there is very little likeli- 
hood of a patient with suspected obstruction passing gas at any 
other time. In regard to the bladder function, attention must 
be called to the occasional error of recording the fact that the 
patient has voided involuntarily and not giving the amount (or 
approximate amount) voided. This may seem an impossibility 
when the urination is involuntary, but it is simple enough to tell 



184 MINOR TECHNIC IN SURGICAL NURSING 

whether or not the amount passed was a mere dribble or a large 
quantity. The importance of accuracy in this matter lies in 
the possibility of the patient, instead of having incontinence of 
urine in the accepted meaning of this term, being the victim of 
retention with overflow. In cases of this sort, the dribble that 
is forced out may give the impression of incontinence, while the 
patient has, in fact, a bladder distended with forty or fifty ounces 
of urine. 

4. Medicine and Treatment Sheet. — This sheet (Fig. 78), as 
the other, has a place at the top for the name of the patient. It 
should be divided into five vertical columns for the recording of 
the following data: date ordered; time ordered; medicament, 
frequency and manner of administration; and date when dis- 
continued. This gives at a glance just what the patient is re- 
ceiving in the line of medicine and treatments, and whether or 
not any of them have been discontinued. 

In addition to the four sheets already mentioned and de- 
scribed, there are four that are for the use of the house staff of the 
hospital. These are: (1) the history blank, for the brief out- 
lining of the salient points of the history of the disease from which 
the patient suffers, with additional spaces for a brief record of 
the treatment of an operative sort; (2) the history sheet for the 
full and careful recording of the past and present history of the 
patient's condition; (3) the urinalysis sheet for the recording of 
the results of the examination of such specimens of urine as may 
be sent to the laboratory; and (4) the pathological sheet for the 
recording of the results of the examination of such pathological 
specimens as may have been sent up for diagnosis. The specimens 
under the latter head may be blood, faeces, sputum, stomach 
contents, or any removed tissues. The four last mentioned 
sheets should be placed on the chart at the back, when it is first 
made up for use. If it chances that they are not used, they may 
be later removed. 

In some hospitals there is another special sheet employed 
during that period which an operative case spends in the recovery 
room. The regular ward order book is not here convenient for 
the writing of orders for the patient, and the stay is frequently 
very abbreviated before transference to the ward. A supple- 
mentary sheet, ruled so as to have columns for date, hour and 
order, is supplied and kept on the chart. All orders, prior to 
patient's removal to ward, are written on this sheet and, thus, 



CHARTS AND RECORDS 



185 



Date. 



Name. 



No.., 

Sheet No. 



6/23/15. 

6/24/15. 

6/25/15. 

6/26/15. 
2.15 P.M. 
9.00 P.M. 

6/27/15. 

6/28/15. 

7/3/15. 
7/6/15. 



Send specimen of urine to laboratory. 
01. ricini Bi at 9 a.m. to-morrow. 
Liquid diet. 
B. 
Prepare for operation at 9 a.m. 
S. S. enema in a. m. 

Morphine sulphate gr. %; atropine sulphate gr. Kso by hypo., 
before leaving for operating room. 
B. 
Hot water ad lib. 

Catheterize in 8 hours if necessary. 
Morphine sulphate gr. % by hypo, now, and repeat if necessary. 

B. 
Liquid diet, without milk. 

B. 
S. S. enema now. 

G. 
Morphine sulphate gr. % by hypo. 

B. 
Catheterize p. r. n. 

E. E. M. 
1-2-3-enema in a.m. 

G. 
Soft diet. 

S. D. B. 
Urotropin gr. xv t. i. d. 

B. 
Pil. A. B. &S. No. iiq., p.m. 
Specimen of urine to laboratory in a.m. 

G. 
Light diet. Irrigate bladder b. i. d. with 2 per cent, boracic 
acid solution, until clear return. At completion of irrigation, 
instil and leave argyrol (15 per cent.) §ss. 
S. D. B. 



Fig. 78. — Medicine and treatment sheet. 

return to the ward with the chart and such orders as have not 
been discontinued are conveniently recorded for continued 
execution. 

A careful study of the illustrated sheets will give a good idea 
of how the various records appear in practical work. 

A full chart, on any serious case, would thus consist, at the 
beginning, of eight sheets. As the condition progresses, succes- 
sive additions are made as the record increases, and, after opera- 
tion, the necessary recovery ward sheet is added. 



PART IV— THE PATIENT 



CHAPTER XIV 

OBSERVATION 

I. THE NURSE AS AN OBSERVER 

A very important part of the work of the nurse consists in 
the observation of the symptoms and condition of the patient 
during the absence of the physician or surgeon. The doctor 
sees the patient once or at most twice in the twenty-four hours, 
and then only for a few minutes. For a knowledge of what hap- 
pens in the intervals he is dependent on the nurse, and while he 
is absent many things may occur of the greatest importance in 
relation to the diagnosis, prognosis, and treatment of the case. 
It may be noted in the first place that the object of the observa- 
tions made by the nurse is quite different from that of those 
made by the surgeon. His primary purpose is the diagnosis of 
the condition, and his chief attention is given to the facts which 
have a bearing upon that problem. The nurse is not directly 
concerned with the diagnosis, that is not her business, although 
her observations may often help materially to that end. The 
primary object of the nurse's observations is the discovery of 
premonitory symptoms, which foretell a change in the course of 
the disease or the coming of a complication. In surgery the 
work of the nurse as an observer is of supreme importance in 
the period of morbidity and of hazard following an operation. 
The character and meaning of the symptoms to be noted by the 
nurse in connection with post-operative complications will be 
considered in a separate chapter. In this place we shall discuss 
the meaning and the methods of observation itself and a brief 
outline of the field of observation within the province of the 
surgical nurse. 

II. THE MEANING OF OBSERVATION 

Observation means the act of noting intelligently some fact 
or occurrence that is pertinent to the subject matter under con- 
sideration or to the work in hand. In practice the observer, 
whether in scientific investigation or in technical work of any 
kind, is required to do three things : (1) to observe, (2) to measure, 
(3) to record. To observe properly requires, in the first place, 
knowledge. Simply to see or hear or touch a thing is not to 

189 



190 THE PATIENT 

observe it. Observing implies, not indeed full knowledge of what 
the thing seen means, but at least a recognition of the fact that 
it has a probable meaning pertinent to the matter in hand. The 
greater the ignorance of the observer, the greater is the certainty 
that he will overlook important facts and occurrences. The 
wider his knowledge, the more certain it is that he will note all 
the facts that have a bearing on the case. The second requisite 
for a good observer is attention, for this means clearness of the 
impression received from seeing, hearing or feeling the thing 
observed, and the third is interest, for without interest continued 
attention is difficult if not impossible. Finally, the observer 
must possess an attribute which is perhaps the most important 
of all and at the same time the most difficult to attain. It is 
that attitude of mind which permits its possessor to be satisfied 
with nothing else than the exact truth, without regard to its 
agreement with preconceived ideas or personal wishes. It is so 
easy to deceive ourselves into the belief that we see something 
that we wish to see, or that we strongly expect to see. An obser- 
vation that is inaccurate is worse than useless, because it is 
misleading. The need for accuracy also makes it imperative 
that the phenomena observed should be measured whenever 
possible, and that the result of the observation should be set 
down in writing at the time it is made, for memory unaided is 
an untrustworthy repository for facts. 

III. METHOD IX OBSERVATION 

System and a regular plan of procedure are essential to 
thoroughness and completeness in any undertaking. If the obser- 
vations of the nurse are made only when some symptom or 
change in the patient's condition forces itself upon her attention, 
many important facts will quite certainly be overlooked or dis- 
covered too late to save the patient, it may be. from unpleasant 
consequences. For this reason the nurse should learn to follow 
as far as possible a definite plan in her observations of the patient's 
condition. This means that she should direct her attention suc- 
cessively and at suitable intervals of time to different aspects 
of the case, so that all the ground may be covered thoroughly, 
and no important new development escape her notice. Thus the 
temperature is taken and the pulse and respiration counted at 
regular hours, varying with the gravity of the condition. The 
character and amount of the excretions are regularly noted. 



OBSERVATION 191 

Known danger signals that are likely to appear should be borne 
in mind, and the attention deliberately directed to determine 
their presence or absence often enough to ensure their prompt 
discovery. Different regions of the body should be inspected 
regularly according to the circumstances of the case, as the abdo- 
men for distention, the back for bed-sores, the bandages for 
staining with blood or other discharges, etc. Symptoms that 
tend to gradual increase should be noted at stated intervals, 
and those that tend to recur at certain periods should be looked 
for at the proper time. Attention should be directed from time to 
time to detect disturbances of the circulatory, respiratory, diges- 
tive, genito-urinary, and nervous systems. When a symptom is 
obscure or its presence doubtful, repeated observations should be 
made from time to time, to verify or correct the first impression, with 
intervals between the observations during which the attention is 
directed to other matters. Observations should be systematically 
entered on the records, and these should be kept fully up to date. 

IV. THE SIGNIFICANCE OF SYMPTOMS 

The inexperienced nurse will often be at a loss to determine 
whether a symptom has any significance at all, or in other cases 
whether it is of such importance that the surgeon should be 
informed at once. Facts that have no bearing on the case should 
not be recorded. Their presence in the record is not only useless 
but confusing. To enter an observation that is not pertinent to 
the case, or to summon the doctor unnecessarily, is a humiliating 
confession of inexperience. To omit the record of an important 
symptom, or to fail to send for the doctor at the earliest appear- 
ance of a danger signal, is not only a confession of inexperience 
but a grave dereliction of duty. There are occasions when the 
experienced nurse, or, for that matter, the experienced surgeon, 
may be puzzled to determine offhand whether a certain symptom 
has any significance, and the first rule of conduct is, " When in 
doubt act always on the safe side." There are, however, certain 
considerations which will assist the nurse in deciding as to the 
importance of a symptom. 

1. Severity. — Every severe symptom is of importance, 
whether its relation to the case is apparent or not. 

2. Duration. — A slight or moderate symptom that is tran- 
sient may mean little or nothing, but if it persists it should 
receive serious consideration. Hiccough as a transient symptom 



192 THE PATIENT 

is : no moment, but persistent hiccough in some cases of disease 
is a symptom of the gravest import. 

3. Tendency to Recur. — A symptom that tends to recur 
persistently may be regarded as having significance. 

4. Progressive Development. — A -;.-mptom that increases in 
severity from hour to hour is always important. 

5. Known Character as a Danger Signal. — For example, a 
sudden abdominal pain, whether severe or not. occurring in the 
third week of typhoid is very likely to mean a perforation, and 
the physician should be called at once. 

6. Relation to affected region, or to the physiological system 
involved in the disease. For example, all digestive or abdominal 
symptoms are important after a laparotomy. 

7. Association with Other Symptoms. — A syrn::':o:n :La: 
would be of no importance by itself may, when associated with 
other symptoms in a group that is known to have a definite 
meaning, become of the utmost significance. A sigh, even if 
often repeated, is not a symptom of importance by itself, but 
sighing respiration associated with great restlessness, anxious 
expression of the face, progressive pallor, etc.. means that a 

ngerous hemorrhage is going on. 

5. Disposition of the Patient. — In estimating subjective symp- 
toms the tendency of the patient to exaggerate or minimize his sen- 
sations must be taken into account. Physical evidences outweigh 
his statements if they contradict them, but at the same time the 
nt ? s sincere complaints should never be too lightly regarded. 

V. THE CONDITIONS WHICH REQUIRE THAT THE BURGEON 

SHOULD BE CALLED 

nnot be defined with ea ; . The}' may be briefly 

summarized as follows : 

1. ^"hen the presence of any danger signal, or premonitory 
.ptom of a serious complication, is recognized. 

2. When a progressive change for the worse is taking place 
in the patient's condition. 

3. When symptom arises not provided for in the 
orders already reeeiv 

4. When the nurse is in doubt. 

:ng to the telephone to summon the surgeon the nurse 
should h • answer any questions as to the patient's 

condition since his last visit. 



OBSERVATION 193 

VI. OBJECTIVE SYMPTOMS AND SIGNS 

Every symptom is either objective or subjective in character. 
An objective symptom is one that is manifest to the observer 
through any of the senses, usually of sight, hearing, or touch. 
The patient ma}^ or may not be aware of it. A full enumeration 
and discussion of objective symptoms would require a volume 
in itself. Many of them must be observed and recorded by the 
surgeon or physician rather than by the nurse. Those symptoms 
(whether subjective or objective) which do lie within the field 
of observation of the nurse are: (1) temperature, pulse, and respi- 
ration, (2) initial symptoms which mark the onset of a disease, 
(3) premonitory symptoms which foretell the coming of a compli- 
cation, (4) symptoms whose fluctuations from hour to hour are 
significant, (5) symptoms of sudden development. The initial, 
premonitory, and other symptoms which are of particular sig- 
nificance in the work of the surgical nurse are considered else- 
where. We can do little more here than present a list of some of 
the more important objective symptoms and signs without at- 
tempting to discuss them. 

There are four symptoms which are of unique value in the 
study of disease. Three of these have been for many years the 
most constantly observed of all symptoms, while the fourth is 
rapidly coming to be recognized as of equal importance with the 
others, particularly to the surgeon. They may be called the 
index symptoms, since they are always present, they can be 
readily measured with accuracy, they are subject to rapid varia- 
tions, responding promptly in many cases to changes in the 
progress of the disease, and their recorded measurements present 
a fair index of the patient's condition. They are : (1) the tempera- 
ture of the body, (2) the respiration, (3) the pulse, (4) the blood- 
pressure. 

The temperature and the blood-pressure have each only one 
element to be considered. It is the rise or fall measured on a 
scale in degrees of temperature in one case and in millimetres of 
mercury in the other. In the case of the pulse and respiration 
there are other elements beside frequency to be considered, so 
that each of these presents a group of symptoms rather than a 
single one. Changes in the regularity and volume of the pulse, 
as well as its rate, are to be observed, and the respiratory system 
presents a large group of symptoms in addition to the frequency 
of respirations. Observation of the blood-pressure must be made 
13 



194 THE PATIENT 

by means of a special and rather complicated instrument and 
is usually done by the physician. A falling blood-pressure 
is the most reliable premonitory symptom of shock, and is of 
special value on the operating table. 

Certain objective signs with regard to the general aspect of 
the patient are to be observed. The position of the body is 
sometimes significant. It may be relaxed and flaccid from weak- 
ness, or stiff and rigid from pain, with knees drawn up to relieve 
hip or abdominal pain, sitting up through inability to breathe 
lying down (orthopncea). curled up on one side through inability 
to lie on the other side or back, with arms thrown over the head 
to assist breathing in air hunger, etc. 

The expression of the face is important in certain cases. 
Dulness. apathy, or lack of expression is seen in shock, in extreme 
weakness, and in toxaemia with fever. The so-called " anxious 
expression " is of special importance. It is difficult to describe 
but readily recognized when seen. It occurs in several acute 
affections of sudden development and grave import, such, for 
example, as obstructed breathing, peritonitis, and particularly 
hemorrhage. 

Movements of the body may require to be noted, such as 
restricted movements from tenderness in joints or muscles, rest- 
lessness, tossing and turning from side to side, twitching of mus- 
cles, spasms, and convulsions. 

Changes in the color of the skin should be observed. Chronic 
pallor will be observed and recorded by the physician in the 
history of the case. Acute or sudden pallor may be transient, 
as in nausea, or lasting or perhaps progressive, as in shock and 
hemorrhage. The pallor has a yellowish tinge in profound 
anaemia, in slow, long-continued hemorrhage, and after a severe 
acute hemorrhage. It is a bluish pallor, due to the blood settling 
in the small veins, in shock, and at the beginning of an acute 
hemorrhage. Cyanosis is the bluish color of the skin, such 
seen in the face after holding the breath. It means lack of 
oxygen in the blood, and is usually associated with difficult 
breathing (dyspnoea). The yellow color of jaundice is a chronic 
symptom and will be recorded by the physician. Excessive 
dryness or moisture of the skin may call for notice, particularly 
the drenching sweats that occur in septic infection, usually 
during sleep. Local swelling of the skin, without redness, may 
be due to oedema, a watery infiltration, or, rarely, to emphysema: 



OBSERVATION 195 

that is, an infiltration with air or gas. This latter condition occurs 
sometimes when the lung has been wounded, the air finding its 
way into the subcutaneous tissues. Infection with the gas 
bacillus also produces it. On pressure the skin yields with a 
soft crackling that can be felt and heard, or the skin may become 
so tense with gas that tapping on it gives a drum-like note. 
When observed it should be reported at once. The abdomen 
should be observed, particularly as regards distention with gas, 
after operations involving the peritoneum. 

The following observations should always be recorded by the 
nurse : 

Symptoms connected with the nervous system: excitement, 
delirium, mental dulness and slowness in response, excessive 
weakness, unconsciousness, coma. 

Sleep: its time, duration, and character, quiet, restless, with 
sudden startings, etc. 

Chills: time, duration, severity, degree of cyanosis if present. 

Vomiting: time, amount, character, including consistency 
(watery, mucous, particles of food, fresh blood, coffee-ground 
material, due to altered blood, etc.) ; color (watery, yellow, brown, 
green, etc.); eructations of gas, regurgitation (spitting up mouth- 
fuls of fluid), etc. 

The excretions: perspiration if excessive; urine, time when 
voided, amount (measured) and character if abnormal (very dark 
in color, very cloudy, bloody, containing sediment, very strong 
odor, etc.). 

Vaginal discharges, including the occurrence of menstruation. 

Movements of the bowels: simply the number and time if 
normal. The character should be noted if abnormal in any 
respect (fluid, watery, watery with particles, bloody, containing 
mucus, undigested food, etc.); the color, if black from the pres- 
ence of altered blood or clay colored from the absence of bile. 
After an operation for gall-stone disease, with common duct 
obstruction and jaundice, particularly when the stools have been 
clay colored before the operation, the color of the stools should 
be regularly noted during the period of morbidity. The result 
of enemas should be recorded (retained or partly retained, not 
returned, returned clear, returned discolored, yellow or brown, 
slightly or moderately, etc., with few or many particles or hard 
masses, etc.). " Good result " on the record means a liquid or 
partly formed stool normal in amount and character. 



196 THE PATIENT 

VII. SUBJECTIVE SYMPTOMS 

Subjective symptoms are those that are manifested only in 
the consciousness of the patient. They are. in other words., the 
sensations and feelings experienced by the patient. We may 
divide them into four groups: (1) symptoms affecting the special 
senses (sight, hearing, touch, taste, smell), (2) pain, (3) organic 
sensations. (4) feelings. 

1 . Symptoms connected with the special senses are important 
in the specialties which deal with diseases of the eye and ear 
and nervous system, and in some instances in general surgery, 
but they belong as a rule within the field of observation of the 
doctor rather than the nurse. 

2. Pain is the most universally recognized symptom of disease. 
Its office seems to be principally that of directing the attention 
insistently to the seat of the chsea.se or injury. It varies in inten- 
sity in even' grade, from barely noticeable pain to pain so ago- 
nizing that loss of consciousness ensues. It varies also in character. 
We have many words descriptive of pain, the aptness of which 
even- one recognizes, such as sharp, dull, aching, gnawing, boring, 
shooting, throbbing, smarting, burning pain, etc. One striking 
characteristic of pain is its distinct localization. There is no 
such thing as general pain, although pain is sometimes felt as 
more or less vaguely diffused through a part of the body. Pain 
may be continuous or paroxysmal (coming " in spells "). It may 
be constant or elicited only on movement or pressure (tenderness). 
Pain may be felt at the seat of disease or " referred " to some 
other area, or both. Examples of referred pain are the pain felt 
in the knee in hip disease, and that under the left shoulder-blade 
in gall-stone disease. Wherever inflammation is present localized 
pain associated with tenderness is always felt. When reporting 
a complaint of pain on the part of the patient, its exact location 
should be given. First the region of the body should be men- 
tioned, head, neck, chest, abdomen, back, arm, forearm, hand, 
thigh, leg. foot; then the part of the region affected, back or 
front; upper, lower or middle part; also whether on the left or 
right, outer or inner side. If pain in the wound or in a joint is 
complained of, only the affected part need be mentioned. The 
character of the pain should be given in the patient's own descrip- 
tive word-. 

3. Organic sensations are those connected with the internal 
organs, such as hunger, thirst, want of appetite (distaste for food), 



OBSERVATION 197 

(the sense of having had enough); nausea, sensations of fulness 
or emptiness in the region of the stomach; the desire to micturate 
or go to stool and their abnormal forms (dysuria, strangury, 
tenesmus); vertigo, swimming in the head, sensations of vague 
discomfort in one region or another, etc. Organic sensations are 
characterized by being very vaguely localized. They vary in 
intensity but not so sharply or through such an extended scale 
as in the case of pain. When very intense they merge into painful 
sensations. Some of these mentioned are physiological and 
natural, and become symptoms only when exaggerated or sup- 
pressed. 

4. Feeling means strictly the experience of pleasantness or 
unpleasantness arising from and associated with a sensation or 
perception. We speak of feeling happy or amused or sad as the 
result of some occurrence or experience. Feelings of admiration 
or of disgust are aroused by others. We also speak of feeling 
thirsty or hungry or dizzy, and not incorrectly, since the idea 
expressed may include the pleasant or unpleasant experiences 
associated with these organic sensations. It is therefore not easy 
to draw a sharp line between feelings and organic sensations as 
symptoms. The symptoms which we may classify under the 
term " feeling " are in reality experiences of pleasantness or 
unpleasantness associated with organic sensations that are so 
vaguely sensed, and so unlocalized, that they fail to be recognized 
as sensations at all. Such are the feeling of general well-being 
of the convalescent or the person in buoyant health, " feeling 
fine," or of vague general discomfort, " feeling badly"; feelings 
of lassitude, of languor, of fatigue, of weakness, of faintness; also 
" feeling stronger," " feeling better," " feeling like getting up," 
etc. These feelings of the patient, however vague and unanalyz- 
able, may be nevertheless symptoms of definite value. Knowing 
how the patient feels helps us often to estimate correctly his 
vital status, to picture to ourselves his position at the moment 
on the road between health and disease. Feelings are, however, 
peculiarly liable to exaggeration or the reverse, and they lack 
the weight of evidence, as well as the precision, of objective signs. 
It is to be remembered also that all the subjective sensations 
and feelings of the patient will, if above a certain grade of inten- 
sity, always be accompanied by definite objective signs. Thus, 
with intense pain there will be, beside the expression of the face, 
the writhing movements and the cry or moan, rapid respiration, 



198 THE PATIENT 

dilated pupils, tense pulse, drops of perspiration on the skin, a 
large amount of clear urine, nausea, faintness and syncope. 
With nausea there will be pallor of the lips and later vomiting, 
and so on. The patient's " feeling badly " will often be found 
to be a reflection of a change for the worse in his temperature, 
pulse, etc., and may be the first thing to call the observer's 
attention to the change. A sudden complaint of " feeling badly," 
therefore, always calls for an observation of the index symptoms. 

VIII. MEASUREMENTS AND QUANTITATIVE ESTIMATIONS 

1. Measurement means the exact determination of quantity 
or magnitude of the thing measured. It is done by comparing 
the magnitude to be measured with some smaller magnitude of 
the same kind which has been selected as a standard unit for 
the comparison. We say a line is so many inches long, a vessel 
contains so many fluidounces. Immaterial forces, such as the 
force of gravity or the intensity of light or heat, can be measured 
as well as material things. A man weighs so many pounds, an 
electric light bulb is of eight, sixteen or thirty-two candle-power, 
the temperature of the air is so. many degrees, and so on. 
Quantitative determinations are of the greatest importance in 
scientific study as well as in the daily business of life, and there 
are many applications of this method in medicine. The body 
temperature is measured by the clinical thermometer. Exact 
measurements are employed in chemical analyses in the clinical 
laboratory. The blood-pressure is measured by a special instru- 
ment. There are many instruments of diagnosis designed for 
the purpose of making exact measurements, particularly in the 
field of ophthalmology. The tape line is used to measure various 
departures from the normal in the body. The amount of urine 
is measured in ounces or cubic centimetres, and the same is true 
of the amount of fluid administered by mouth or by rectum or 
subcutaneously. Doses of medicine are measured by weight or 
volume. Time measurements are employed in determining the 
rate of the pulse and respiration. 

In the observation of symptoms, however, we are met at 
once by an apparently insuperable difficulty. Many of them are, 
for various reasons, not susceptible of measurement. For 
example, we cannot measure by any available means the amount 
of perspiration, or of discharges saturating a dressing, or the 
degree of cyanosis or of pallor, or the amount of pressure that 



OBSERVATION 199 

will produce pain in a tender spot. For measurements of pain 
we have no unit for comparison and no way to apply it if we had 
one. In the case of pain and other subjective symptoms, there 
is the added difficulty that they are not within the experience of 
the observer. It is the patient who experiences them, and the 
observer therefore must depend on the patient's own report, 
which is often exaggerated or sometimes the reverse. 

2. Quantitative Estimations: The Scale of Seven. — As a 
substitute for measurement, in the case of these unmeasurable 
things, we may employ a graded series of quantitative judgments. 
In regard to many things that we can observe but cannot measure 
we are able at once to form a judgment of magnitude in three 
grades, small, of moderate amount, large; or weak, of moderate 
strength, strong; or slight, moderate, severe; and so on. We can 
easily add two more grades, one at each end, as very weak or 
very strong, and finally we can introduce an intermediate grade 
between weak and moderate, and another between moderate 
and strong which we may call respectively rather weak and rather 
strong. We have thus a scale of judgments of magnitude of seven 
grades, which is as far in the direction of subdivision as we can 
safely go. If the seven divisions be designated by numbers, the 
even numbers (2, 4, 6) stand for the three primary judgments, 
and the odd numbers (1, 3, 5, 7) for the intermediate grades. 

Our scale then stands thus: 

(1) Very small. Very weak. Very slight. 

(2) Small. Weak. Slight. 

(3) Rather small. Rather weak. Rather slight. 

(4) Medium. Moderate. Moderate 

(5) Rather large. Rather strong. Rather severe. 

(6) Large. Strong. Severe 

(7) Very large. Very strong. Very severe. 

In practice it will be best to make first an offhand judgment 
on the primary scale (Weak, Moderate, Strong) and then, more 
deliberately, a supplementary judgment, which will be either the 
same as the first, or one point above or below, thus — primary 
judgment, moderate (4), supplementary judgment, rather slight 
(3) . In bedside notes the numbers may be used, out in the perma- 
nent record the descriptive words should always be written out. 
Thus (4), (3) will read, " moderate, or rather slight " as applied 
to whatever is being estimated. 

These quantitative judgments, of course, have no claim to 
rank as exact measurements, and there will be rather wide varia- 



200 THE PATIENT 

tions in the judgments of different individuals. In regard to 
subjective symptoms, the estimate must be based on the patient's 
own report, but this can often be supplemented by the observable 
manifestations of the symptom. In the case of pain, for example, 
rather severe pain (5) may be taken to be that which will be 
clearly evident in the expression of the face; severe pain (6) will 
show in the voice, or by cry or moan; while very severe pain (7) 
will be manifested by such other signs of pain as pallor, quickened 
respiration, moist skin, etc., so that even here we do not have 
to depend on the patient's report solely, except in the case of 
the slight and moderate degrees which are usually of less signifi- 
cance. These objective signs should always be recorded as 
observed. 

When a quantity of fluid is to be estimated, it may be done 
by a rough guess at the amount, as for instance, " about two 
drachms " or " about four ounces." When this is done the 
abbreviation (est.) should be added to indicate that the amount 
is estimated and not measured. The degree of accuracy required 
in measurement, or the limit of permissible error, varies according 
to the object in view. The weight of a dose of atropine should be 
correct within a thousandth of a grain, while a dose of Epsom 
salts may vary a number of grains without harm. The amount of 
urine frequently requires to be measured with accuracy, but the 
amount of vomited material need only be roughly estimated. 

The measurements to be regularly made by the nurse include 
the temperature, rate per minute of the pulse and respiration; 
the quantity of urine voided and of liquid taken; the amount of 
salt solution given, under the skin or by rectum; enemata and 
medicines. 

3. The record made by the nurse should be (1) brief, (2) a 
simple statement of the facts recognized by sight, hearing, or 
touch, without an expression of opinion as to their cause, (3) ac- 
curate, (4) clear. Vague statements should be avoided. Each 
observation should be recorded by itself, and the time of its 
occurrence stated. 



CHAPTER XV 

MEASURES FOR THE COMFORT AND WELL-BEING 
OF THE PATIENT 

A large part of the work of the nurse is carried out under 
either standing or special orders written down in the order book 
by the surgeon or physician in charge of the case, and her respon- 
sibility is then limited to obedience and the proper exercise of 
the technical knowledge and skill acquired in the practice of her 
profession. The doctor is the one who is responsible for the 
treatment of the disease or affection which brings the patient 
under his care. It is his part to determine what remedial meas- 
ures shall be employed, and it is the part of the nurse to carry 
out, under his orders, such of them as come within her province. 

There is, however, a part of the nurse's work in which she is 
left to act largely on her own responsibility, without general or 
special written orders, in applying the knowledge and skill she 
has acquired in the course of her training with regard to the 
proper care of the sick. This field of the work of the nurse con- 
cerns the general well-being and comfort of the patient. It is, 
from the patient's point of view, the most important part of 
nursing, and it often calls for the highest degree of discretion and 
good judgment on the part of the nurse. Pain and suffering, 
both physical and mental, are inseparable from disease and injury, 
and in their alleviation efficient nursing plays the principal part. 

It is assumed that the nurse is instructed in regard to the 
general hygiene of the sick-room, the care of the bed, the bath, 
adequate ventilation and the flushing of the room with fresh air 
at suitable intervals, the proper arrangement of light, the serving 
of food in attractive form, and prompt attention to the essential 
needs of the patient, the prevention and care of bed-sores, and 
the alleviation of the many small discomforts incident to every 
illness. We shall consider in this chapter some points in surgical 
nursing to which insufficient attention is often given by the 
nurse, and it must be said by the surgeon as well, resulting in 
much unnecessary discomfort to the patient, and sometimes in 
lasting injury. 

201 



::•: the patient 

i. position in bed 

The dorsal position, prone on the back, is the position in 
which the patient is usually placed in bed immediately 
operation- It is the natural position of complete relaxation and 
exhaustion and can be maintained longer than any other without 

mi rt There are. however, grave objections to prolonged 
lying on the back. It is a contributing cause ::' by -~ " 
pneumonia and of cystitis, and a direct cause . : bed-sores 
Change of position by turning the patient on the side, if nece- 
with supporting pillows under shoulder and hips r should be 
encouraged and even insisted on whenever possible. Ther- 
only a few conditions in which a continued dorsal position is 
unavoidable, and abdominal operations are not among them. 

:te of the common pr : keeping these patients on the 

back. The methods of treat::: % h ~ ires of the thigh and hip ? 
which are still most frequently employed, compel the patient 
to lie on his back for mar: M -■> -" -"--- - changes 

of position can be managed without harm, if proper discretion 
and care are used : indeed, the patient will soon learn to ease him- 
self by shifting his body about, and may have fcc be cautioned 
against too free movements. After lominal operations a 
pillow placed under the knees so that the thighs are slightly 
flexed adds greatly to the comfort of the patient. The head and 
usually the shoulders may be supported with pill us :~:r all 
operations as soon as the patient finds them comfortable. 

7 covering should be warm and light and not too smoothly 
and tightly tucked in around a weak and help. 
point in this connection needs particular emphas> 1 "ients 
who are bed-ridden for a long time are v ne to develop 

I • "-irop, the feet becoming fixed in an extended position by 
the contraction of the calf muscles, a condition that may take 
week a month- - welcome after convalescence is estab- 

lished, the patient meantime beir__ - djy crippl- I is an- 

noying complication is wholly preventable and the principal 
cause of it is the careful smoothing and tucking in of the I 
bed coverings, which adds so much to the neat appearan 
the ward while at the same time it fix - - wakened patient's 

in the extended position as if with immovable splints. In 
all cases, whether ! or medical., where the patie:.* a 
fined to the bed for a long time, the bedclothes over the 
shou si left loose, and careful 

q should be given to the position of 111 



COMFORT AND WELL-BEING OF PATIENT 203 

II. APPLICATION OF HEAT AND COLD 

Applications of heat and cold by means of hot-water bags or 
bottles, ice-bags, or of cloths wrung out of hot or cold water, are 
measures within the discretion of the nurse. Keeping the patient 
warm with water-bottles and blankets is a routine procedure 
after all severe operations followed by shock, but is one that is 
liable to grave abuse. To make clear why this is so, and what is 
the real object to be attained, an explanation is necessary. The 
so-called warm-blooded animals, including birds and mammals 
(of which latter class man and the four-footed domestic animals 
are examples), possess a heat-regulating mechanism, under the 
control of the nervous system, which maintains a balance between 
the production of heat within the body by the chemical activities 
of the cells, and the loss of heat from the surface, through radia- 
tion and evaporation, so that the actual temperature of the body 
is kept at a nearly constant level. Thus the temperature of the 
circulating blood is independent of surrounding conditions. It 
is the same in winter as in summer, in the arctic as in the tropical 
regions. In the case of the cold-blooded animals this is not so; 
their body temperature varies with their surroundings. The 
temperature of reptiles and fishes is at all times the same within 
a few degrees as that of the water or air within which they live. 
This is their normal condition, to which they are adapted, and 
they are able to withstand very great changes in body tempera- 
ture without ill effect. Some of them can survive chilling even 
to the freezing point. Warm-blooded animals are therefore 
called homceothermic, that is, with unvarying heat; while cold- 
blooded animals are poecilothermic, that is, with changing heat. 
Warm-blooded animals are able to endure only a limited change 
of temperature. Cases are on record of persons exposed to 
extreme cold, without sufficient protection to maintain the body 
heat, who have recovered after the rectal temperature has fallen 
to 76° F., but when the rectal temperature has fallen to 70° F. 
death invariably ensues. Thus when men " freeze to death/' 
they die before the circulating blood has reached what is regarded 
as a comfortable room temperature. Now under certain condi- 
tions the human body becomes in a sense poecilothermic, that 
is, it tends to assume the temperature of the surrounding medium, 
although it does not become adapted to sustain such changes 
without harm. Prematurely born infants are in this condition, 
and those born at term are partially so for a time. But the condi- 
tion of poecilothermism of particular interest to us is a surgical 



204 THE PATIENT 

one. In surgical shock and in severe hemorrhage the heat-con- 
trolling mechanism fails. The temperature tends to fall to that 
of the surrounding medium, and such patients may " freeze to 
death " through exposure to ordinary room temperature. In 
these conditions the loss of heat must be prevented by proper 
coverings and the surrounding temperature maintained at or a 
little above the normal level. The water-bottles surrounding 
the patient therefore should be warm but not hot. since the object 
is. not to raise the patient's temperature, but to prevent loss of 
heat from the surface. -In additional reason for having the water 
in the bottles at a moderate temperature is the great Hability 
of the unconscious patient to be badly burned by contact with 
a bottle that is even moderately hot. This unfortunate accident 
has occurred, at one time or another, in almost every hospital. 
It results not only in great and prolonged suffering to the patient, 
but often in expensive litigation against the hospital authorities. 
The accident is inexcusable because it is so easily preventable. 
The usual teaching is that the bottles should be placed at a 
distance from the patient, with layers of blanket between in 
order to prevent burning, but this is not the proper remedy. The 
patient, tossing about, is sure to come in contact with the bottles 
in spite of this precaution. The temperature of the water in the 
bottles must be low enough so that they cannot possibly burn. 

Sloughs may also be caused by the ice-bag if it is kept too 
closely or too long in contact with the skin. Several layers of 
gauze should always be placed between the bag and the surface 
of the body, and the bag itself should be removed for a short 
time at least every hour or two. 

Hot wet dressings form the best local treatment for all forms 
of septic infection. When frequent changes of such dressings 
are desirable this duty may be entrusted to the nurse. Local 
heat is employed also for the relief of pain, and this is almost 
the sole indication for the application of cold. 

III. MEASURES EOR THE RELIEF OF PAIN 

We have always at hand a method of relieving pain, certain, 
and practically instantaneous; but this easy method carries 
with it. unfortunately, an almost equal facility for doing incalcu- 
lable harm. The first principle, therefore, in the treatment of 
pain is that morphia, the great anodyne, is to be resorted to 
only when absolutely neces-ary. The nur-e is not privileged 



COMFORT AND WELL-BEING OF PATIENT 205 

to administer it without orders from the physician, but such 
orders are frequently provisional, so that the immediate respon- 
sibility for deciding when it shall be given rests often upon the 
nurse. No hard-and-fast rules for her guidance can be laid down, 
but a few suggestions of a general character may be made. When 
morphia is positively ordered the nurse has no choice but to 
administer it: she may, however, interpret as provisional an 
order not so phrased, if there is a reasonable presumption that 
it was intended as such. She may accept as final the patient's 
refusal to take it. The nurse should never insist on the patient's 
taking morphia against his will, except perhaps in the case of the 
routine pre-operative hypodermic. When morphia has been 
provisionally ordered it should usually be withheld for all degrees 
of pain up to and including moderate pain (number 4 in the 
scale of seven). In severe and very severe pain (6 and 7) it 
should be given at once unless the pain is tending to diminish, 
in which case it may be delayed for a time while other simple 
means of relief are tried. Number 5 in the scale (rather severe 
pain) is the dividing line where the nurse must act according to 
her best judgment. The patient should be told that he is better 
off without morphia if he can endure the pain, and he should be 
encouraged in every way in a voluntary refusal to take it. Of 
course it is exactly in the cases where the giving of morphia is 
most undesirable that the patient's own report as to the degree 
of pain from which he is suffering is least reliable. It is particu- 
larly against repeated daily doses of morphia that the patient 
must be guarded by every possible means. In the last stages of a 
hopeless and painful disease most of us feel that these rigid rules 
may properly be relaxed. The other less dangerous and also less 
efficient anodynes may be given with more freedom, but even 
with these great discretion should be used. 

The simple means for the relief of pain vary with the location, 
character, and cause of the pain. Inflammatory pain is always 
associated with tenderness on pressure and, if the superficial 
tissues are involved, with redness of the skin and swelling. The 
application of cold, elevation of the part when possible, and 
removal of pressure help to give relief. The first principle in the 
treatment of pain from trauma is rest; that is, keeping the part 
still. Cold and elevation also assist here. Neuralgic pains are 
usually aggravated by cold: heat and stimulating local applica- 
tions (such as cause a burning sensation and redness of the skin) 



206 THE PATIENT 

help them. Cramp pains in the muscles are relieved by rubbing, 
pressure and heat. Aching in the back and limbs caused by 
strain from lying in the same position for a long time is a frequent 
source of great discomfort to patients. Even very slight changes 
of position from time to time give the greatest relief. Smarting 
pain from slight abrasions of the skin, as at the sharp edge of a 
bandage, are treated by removal of the cause of irritation and 
protection with a dry powder or a soothing ointment. 

Burning and smarting pain, and itching, due to the effect on 
the skin of irritating secretions, may be relieved by cleanliness 
and drying powders, or by simple alkaline lotions, such as carbon- 
ate of soda (1 per cent, solution), or oxide and precipitated car- 
bonate of zinc (two drachms of each to four ounces of glycerine 
and rose water). The most aggravated cases of this form of 
irritation occur when an intestinal fistula has formed involving 
the upper part of the small intestine. The active digestive secre- 
tions from this portion of the digestive tract play dreadful havoc 
with the skin when they are poured out constantly upon the 
surface of the abdomen, and the resulting suffering of the patient 
is constant and almost unendurable. The condition is rare, but 
the suffering is very difficult to control when it occurs. Fecal 
matter soiling the surface from fistulse communicating with the 
lower part of the intestine causes little or no irritation of the skin. 

Pain and discomfort from abdominal distention with gas is a 
common occurrence after operations in which the peritoneum 
has been incised and sutured. It lasts for two or three days or 
until the bowels have moved freely. No sure means of preventing 
it has been discovered, or, at any rate, none is generally known and 
practised. Hot fomentations, enemata and the passage of the 
rectal tube give some measure of relief. Morphia, of course, con- 
trols the pain but tends to aggravate the distention. Pain from 
the operative wound itself is not, as a rule, either severe or lasting. 
Provisional orders for hypodermics of morphia to relieve it are 
commonly given. There is undoubtedly a tendency towards too 
great laxity in this respect both on the part of the surgeon and 
the nurse, and the suggestions already given for the carrying out 
of such provisional orders should be carefully observed. A num- 
ber of other painful conditions may be met with, following opera- 
tions. Practically all of them arise from some form of trauma 
suffered by the patient on the table. The backache already 
referred to is common. It is difficult to relieve and it frequently 



COMFORT AND WELL-BEING OF PATIENT 207 

lasts for many days. Every effort should be made to prevent 
its occurrence. Sore tongue, sore throat, and sore jaw result 
from the efforts of the anaesthetist to overcome obstructed breath- 
ing. A too tight or improperly adjusted bandage may give rise 
to much discomfort or even pain. A distended bladder from 
retention of urine is a common source of discomfort after opera- 
tion. Every effort to avoid the use of the catheter must be made, 
but it is unsafe to delay more than twelve to sixteen hours at the 
most. Too great emphasis cannot be laid upon the necessity for 
strict asepsis in this procedure. The bladder is extremely sus- 
ceptible to infection and the resulting cystitis is a serious compli- 
cation. 

Finally, every effort should be made to assist the patient in 
maintaining a healthy mental attitude towards pain, particularly 
in the long- continued chronic cases where the normal mental con- 
trol is apt to be severely tried. Cheerfulness and a hopeful out- 
look help greatly to lighten the acuteness of physical suffering; 
laughter is a great anodyne for the slighter grades of pain. The 
sole function and business of pain is to seize upon and hold the 
attention, and if it can be prevented from doing this by any means 
at all its power is gone. In its higher degrees of intensity the 
demand of pain upon the attention is imperative and cannot be 
denied, but for the slighter grades any object of interest that can 
occupy the mind is a potent antagonist. Whenever the attention 
becomes fixed on something else pain, if present, rapidly falls in 
the scale of intensity and may even vanish momentarily from 
consciousness like a dissolving view. It is a commonplace obser- 
vation that the patient feels better during the doctor's visit, not, 
of course, because of any soothing virtue in his presence, but 
because the patient's attention is attracted strongly away from 
his own sensations of pain or discomfort. On the other hand, 
moderate pain seems to become more severe if the mind dwells 
constantly upon it, and a morbid mental outlook tends to bring 
into the focus of consciousness all those numberless, slight, 
fugitive and meaningless pains to which every one is subject but 
which pass unnoticed in health. 

IV. WATER AND FOOD 

1. The need for water is the most imperative requirement of 
all living things, and the distress arising from prolonged depriva- 
tion of it is probably not surpassed by any other form of suffering. 



20S THE PATIENT 

One of the most unpleasant memories that patients who have 
had an operation performed under ether anaesthesia carry away 
with them is that of discomfort from thirst. For this reason, 
and also because of the great value of water as a remedy in certain 
conditions, it is important that the principles involved in the 
administration of water in surgical cases should be very clearly 
laid down. 

In the first place, water should be administered freely in all 
surgical cases and at all times. There are, it is true, a few condi- 
tions, to be enumerated below, in which water by mouth must 
be withheld for a time, but this does not mean that water is not 
to be given at all; on the contrary, when it cannot be taken by 
mouth it should be given by one of the other two possible methods 
of administering it; namely, by direct injection into the tissues, 
usually under the skin, or by the rectum. Either of these methods 
is a more direct way of introducing water into the circulation 
than giving it by mouth. There is very little absorption of water 
through the walls of the stomach or small intestine. It is ab- 
sorbed rapidly in the colon and rectum. When injected under 
the skin it passes almost directly into the circulation. Water 
may be given by rectum in one of two ways : either by the con- 
tinuous drop method or by the injection of from eight to twelve 
ounces every two to four hours. Either plain water or normal 
physiological salt solution may be used. The latter must always 
be employed when water is to be given by subcutaneous injec- 
tion: in this case it must, of course, be absolutely sterile. 

In all forms of infection the administration of water in large 
amount is by far the most important part of the internal treat- 
ment. It aids in the rapid elimination of the toxins from the 
blood through the excretions. In cases of severe sepsis the patient 
should be made to take at least a half glass of water even- half 
hour when awake. It is desirable that water should be taken 
abundantly for several days before an operation, and also after- 
wards, as soon as the stomach will retain it. Rectal injections 
of water should be resorted to after all operations when vomiting 
continues for more than a few hours. 

Thirst is a distressing symptom immediately after almost 
every operation when a general anaesthetic has been used. There 
are several causes for this. 

In the first place, the preliminary hypodermic of morphia 
and atropia usually given tends to check the secretions in the 



COMFORT AND WELL-BEING OF PATIENT 209 

mouth and throat, leaving the mucous membrane abnormally 
dry, and the anaesthetic itself aggravates this condition. There 
is also a considerable loss of body fluids at every operation, 
resulting from the preliminary purging, from vomiting, from 
perspiration and from hemorrhage. From these causes many 
patients after operation suffer acutely from thirst, and this is 
increased by the common practice of withholding water alto- 
gether, or giving it very sparingly, for the first twelve hours or 
until the stomach will retain it. When water is withheld because 
of continued nausea and vomiting, the administration of saline 
solution or plain water by the rectal route helps greatly to relieve 
thirst by supplying the body with the necessary amount of fluid. 
Frequent rinsing of the mouth with water adds to the patient's 
comfort, by relieving the dryness of the mucous membrane. In 
the presence of nausea hot water is better borne by the stomach 
than cold. It is more palatable when given in the form of weak 
tea. Sipping cold water in small quantities is not to be recom- 
mended. It does not satisfy the patient's thirst, and is quite as 
certain to induce vomiting as when given in larger amount. 
After operations of such a nature that the act of vomiting in 
itself does no particular harm the restrictions against giving 
water need not be so rigidly observed. The washing out of the 
stomach which ensues is rather an advantage than otherwise, 
tending to hasten the return of that organ to its normal condi- 
tion, by relieving it of a load of ether-saturated secretions that 
have accumulated during the operation. 

The surgical conditions in which water by mouth must be 
withheld are three, or at most four, in number : (1) after operation 
of such a character that the act of vomiting is apt to do violence 
to the wounded tissues, as for example operations on any of the 
organs within the abdomen and particularly upon the stomach 
itself; (2) in cases of acute intestinal obstruction, and (3) in 
general peritonitis. In the two latter conditions it is useless to 
give water by mouth, since it cannot be passed on to that part 
of the intestine where it will be absorbed. Systematic stomach 
washing and, of course, appropriate operative interference are 
indicated in these cases. We may include in a fourth group all 
other cases in which from whatever cause the stomach immedi- 
ately rejects whatever is put into it. 

2. The principles governing the feeding of surgical patients 
may be briefly stated in very simple terms. The disturbance of 
14 



210 THE PATIENT 

digestion caused by the ansesthetic makes it necessary to adminis- 
ter nourishment very sparingly until the stomach has recovered 
its tone. The rule is that, in uncomplicated cases, after the 
patient's bowels have moved, usually on the third day, almost 
any wholesome food may be given in reasonable quantities.. It 
is unnecessary to restrict the patient to a liquid diet through the 
period of healing. When fever is present the rules that govern 
feeding in medical cases with fever apply. After operations upon 
the stomach or intestines nothing is to be given by mouth for the 
first twenty-four hours. On the second day albumen water and 
water or weak tea may be given in small quantities at a time 
every two or three, hours. On the third day broths and light 
gruels may be given. The amount and variety of food are increased 
gradually until at the end of a week a fairly full diet is attained. 

V. ATTEXTIOX TO BANDAGES AND DRESSINGS 

The nurse should regularly observe the dressings over the 
wound to detect staining with blood during the first few hours, 
and later for soiling with discharges from the wound, or with 
urine or fecal matter. Concealed dressings, such as packs of 
gauze in the uterus or vagina, for example, may sometimes be 
overlooked. The nurse should consider that she shares with the 
surgeon, in some measure at least, the responsibility for seeing 
that these are removed at the proper time, and should call his 
attention to them if he has allowed them to remain more than- 
three or four days. 

Pressure from bandages too tightly applied is a not infrequent 
source of discomfort and even pain to the patient. A sharp fold 
cutting into the skin at the edge of the bandage may be trimmed 
away by the nurse. She cannot, of course, except in emergency, 
take the responsibility of cutting the bandage to any great 
extent, but she should report to the surgeon any complaints the 
patient may have made. Bandages around the chest, applied 
while the patient is relaxed and unconscious on the table, are 
particularly apt to be too tight. The resulting restriction to 
chest expansion in the act of breathing, at first felt as a minor 
discomfort, becomes after some hours a positive torture. As the 
nurse may some time be entrusted with the duty of relieving this 
condition, it is well for her to know how it should be done. At 
the side of the patient's body farthest removed from the wound 
the bandage is cut with the scissors, beginning at one edge and 



COMFORT AND WELL-BEING OF PATIENT 211 

extending two-thirds of the way across towards the opposite edge. 
Four inches away from this first cut a second cut is made, begin- 
ning at the opposite edge and extending two-thirds of the way 
across. Both cuts include all the thickness of the bandages down 
to the skin. These two cuts overlap each other in the middle 
third of the width of the bandage, lying parallel and four inches 
apart. The bandage then opens up like a lazy tongs gate, allow- 
ing free chest expansion but not disturbing in the least the 
dressings over the wound. A strip of adhesive plaster or a small 
piece of bandage pinned across each gap at the upper and lower 
edge then makes all secure. 

When splints or a rigid plaster-of-Paris bandage have been 
applied to a limb, pressure over some concealed point may give 
rise to severe sloughing if neglected. Every complaint of the 
patient as to pain or discomfort within a rigid splint or bandage, 
no matter how trivial, should be given careful attention and 
should be reported without fail to the surgeon. If such a rigid 
dressing has been applied to a limb without including the hand 
or foot, as the case may be; and if at any time the hand or foot 
becomes blue and markedly swollen or numb, then the bandage 
must be cut through its whole length and thickness (but not 
otherwise disturbed) so as to allow the circulation of the part to 
be restored, and if the surgeon is not accessible within a reason- 
able time the nurse must assume the full responsibility of doing 
this. Slipping or displacement of a bandage from being too 
loosely applied is a less common occurrence, but one that must 
be borne in mind and, of course, attended to and reported when- 
ever it occurs. 

VI. PRECAUTIONS IN ACUTELY INFECTED CASES 

The precautions to be taken in acutely infected cases (par- 
ticularly those infected with the gonococcus) naturally divide 
themselves into three categories: those for the protection of the 
patient infected; those for the protection of the other patients 
or the household of the infected person; and those for the pro- 
tection of the nurse. 

1. The Patient. — All care should be taken to prevent the 
transference of the infection from its original site to any other 
field. If, therefore, the vulva and vagina are acutely infected, 
great care should be taken to prevent the further infection of 
the urethra, or the carrying of the infection to the eyes. The 



W THE PATTEST 

former is attained by the avoidance of catheterization and the 

careful and persistent cleansing of the parts. The second danger 
is avoided by explanation to the patient of the great danger to 
her sight from any transfer of the infection by hands or clothes 
to the eyes and by careful oversight to prevent the use of any 
cloths or implements by the patient that might by any chance 
have come into contact with the infectious matter. 

2. The Household or Other Patients. — To prevent the spread 
of infection to others, the patient should be subject to what 
would amount to a mild isolation. Great care should also be 
taken that others do not use the same towels, wash cloth; 
other toilet articles, without careful preliminary sterilization. 

3. The Nurse. — For self-protection, the nurse should take 
great care in her treatments to the patient ; in her handling of 
infected dressings; and in her cleansing of her hands after each 
dressing. 

As an additional precaution, no nurse who is attending such 
a case (this pertaining particularly in those hospitals ~ --;- ~..- 
services are not carefully segregated) should be permittei : 
attend obstetrical patients. 



CHAPTER XVI 

ROUTINE NURSING IN OPERATIVE CASES 
I. PREPARATION OF THE PATIENT FOR OPERATION 

The preparation of the patient for operation, while apparently 
a very simple procedure, requires the same forethought and care- 
ful attention to detail that characterizes any of the other pro- 
cedures of surgical and gynaecological nursing. While the various 
steps are more or less routine in character (and may, at times, 
appear somewhat senselessly so), a reasonable and logical cause 
may be found at the foundation of each procedure, and (this 
reason once understood) the conscientious nurse will appreciate 
the importance of adhering as strictly as possible to the minutiae 
of preparation. 

A. Bowel Function. — As, unfortunately, a large proportion of 
our patients, particularly in gynaecological work, are inclined to 
a more or less obstinate degree of constipation, the necessity of 
a thoroughly evacuated intestinal canal should be emphasized. 
Our methods in this direction may be included under the two 
main heads of diet and purgation. The amount of food detritus 
in the alimentary canal is limited by the reduction of the diet 
for a variable length of time before the operation. A strict liquid 
diet for twenty-four hours is generally sufficient, nothing but 
water in small quantities being administered for the last eight 
or ten hours. As regards purgation, the method largely depends 
upon the individual preference of the operator. Some place their 
confidence in broken doses of calomel followed by a saline, the 
treatment being started twenty-four hours before the operation; 
others depend upon a single dose or repeated doses of a saline 
alone; while yet others give a single dose of one ounce of castor 
oil twenty-four hours before the operation. But, whatever the 
purgative used, its administration should sufficiently precede 
the hour of operation to permit of thorough and repeated evacua- 
tion of the bowels before the patient is taken to the operating 
room. And it is equally true that, whatever the form of purga- 
tive used, nearly all surgeons agree upon the use of a final cleansing 
soapsuds enema several hours before the operation. The word 

213 



THE PATIENT 

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more than tire smplfi Kimhnsti : 1 a ^nema. To be cleans- 
mi. tire mema mist tnial &urn 

Bid DBs 

— 7", - ] i i aa . tpeiL liquid <fe 

or jours before tire 50005 setL haul 

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ame time: Afttwmiwg 

.-_:.- . - Una eJH be receive- a 

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pecaiiug: Efc is peri ideat : fed mteati 

in _ • .. ■ :: ury tn . nampulati a :: * tening 

from tie field ; •nxtism than tiioae -vmim ire Sat an 

ma 

. Hragnly -mpr>i :iir •- il rmde 

us material into ire 1 - nin d [ — 
uredi .: lieh . md food 

EmalLy . - - s much facilitate . 

ing lexatioiL am h& .11 is 

mac: lity ire patient t i : nuch 

— i .o:imienr 

1 t time ■ • 

Hminish itkm 

[ting Bran sfa 
ikehnnfl - me nans ■ uniting; and 

me- 
[hanical saus 

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;iL r 1111:! re a soar 



ROUTINE NURSING IN OPERATIVE CASES 215 

other) poultice is used in the preparation, this early shaving 
gives the poultice from twelve to eighteen hours in which to 
accomplish its work before the final preparation. Where the 
iodine preparation is used, it gives the field of operation time to 
thoroughly dry out, the presence of the soap and water used in 
shaving interfering with the antiseptic action of the iodine. The 
process of shaving should be a thorough one, care being taken, 
however, to avoid the making of any abrasions of the skin surface. 
As a general rule, it is better that both abdomen and vulva be 
shaved for every gynaecological operation, unless otherwise 
directed. 

The next step in the preparation of the field of operation 
consists in the various steps that are taken with the idea of 
sterilizing the skin. While it is acknowledged that perfect 
sterilization of the skin is impossible, yet this desirable condition 
can be nearly enough approximated by the methods in vogue 
to render danger of extraneous infection practically nil, if the 
technic of preparation is conscientiously followed. The effort 
has, naturally, been to find a method of skin sterilization that 
would combine simplicity with the aseptic advantages of the 
most complicated methods. The two methods now most popu- 
larly accepted are the old one where green soap and water scrub- 
bing is followed by the successive washing with alcohol, ether 
and a solution of bichloride of mercury in the strength of 1-1000, 
and the newer where the field of operation is simply painted 
with the tincture of iodine (or a solution of equal parts tinc- 
ture of iodine and 95 per cent, alcohol) and permitted to dry. 
Either of these methods gives the desired degree of asepsis and, 
as a result, the newer being the simpler is coming into widespread 
recognition. Whichever method is employed, the time of appli- 
cation is generally the same, on the table, after or during the 
administration of the anaesthetic. 

II. ROUTINE TREATMENT AFTER OPERATION 

In the average operative case, where there is no serious com- 
plication or sequela that may cause the introduction of new ele- 
ments of care or treatment, the large majority of surgeons have 
what might be described as an elastic routine treatment. By 
this we mean that in each operator's experience a certain method 
of procedure has seemed to give the best results in the greatest 
number of cases, so he adheres to that routine where it is not 



216 THE PATIENT 

contra-indicated for one reason or another. While it would, of 
course, not be feasible to enumerate all of the methods of attain- 
ing the same end that have grown up among the various operators 
of large experience, an effort will be made to draw what seems a 
fair average from the wealth of material; to give a general out- 
line of what has proved acceptable to many, and to give the 
reasons for each step, so that it may be understood and the 
reason for variation in any particular technic appreciated. . 

1. Minor Steps for the Comfort of the Patient. — The patient 
who has undergone a laparotomy is brought back to the ward 
with an abdominal wall that has been cut, to a greater or less 
extent; that has been pulled by retractors in the effort to 
reveal the abdominal contents; and that has had its contents 
more or less extensively handled. Any one who has endeavored 
to relieve a plain, old-fashioned cramp by drawing up the knees 
will see a reason for putting a pillow under the patient's knees 
as soon as she shows signs of reacting from the anaesthetic. The 
great discomfort caused by the necessity of lying continuously 
in the same position is hard to appreciate by those who have 
not undergone the experience, but it is sufficiently great to war- 
rant the frequent turning of the patient from side to side as she 
complains of the position she occupies. The feeling that a 
patient must remain flat on the back for an indefinite length of 
time has long passed into the disuse that it deserved. These 
two simple aids (the pillow under the knees and the change of 
position) will add more to the comfort of a patient than all the 
possible assurances of a rapid recovery or that the pain will 
soon wear off. 

2. Administration of Water. — After an anaesthetic two points 
arise in regard to the administration of water. The patient is 
generally very thirsty and, at the same time, very nauseated. 
On the treatment there is a difference of opinion. One body 
believes in the administration of very small (teaspoonful) quan- 
tities of hot or cold water, with the idea of alleviating the thirst 
without increasing the nausea. Others give larger (two ounces, 
or more) quantities, generally of hot water, with the idea of 
assuaging the thirst, regardless of the nausea, believing that, if 
the patient does vomit, this is a very efficient way of washing the 
stomach of the ether that ha- been swallowed during the admin- 
istration of the anaesthetic. 

3. Nourishment. — The nausea following anaesthesia does not 



ROUTINE NURSING IN OPERATIVE CASES 217 

render it advisable to administer any nourishment for several 
hours after reaction. As soon, however, as the nausea permits, 
it is desirable to start nourishment in such a form as is easily 
assimilated by the already upset intestinal tract. Albumen water 
is generally used as a starter, being given first in teaspoonful 
doses, increased as circumstances permit until several ounces are 
being given. Other liquids are usually not administered until 
the completion of the first twenty-four hours after the operation, 
at which time full liquid diet (without milk) is instituted. But, 
why is milk omitted? Owing to the anaesthetic and the manipu- 
lation of the intestines during the course of operation, there is 
a varying degree of intestinal paralysis for the first few days after 
an operation. This condition naturally favors the formation and 
retention of gas. Intestinal gas is one of the most prominent 
causes of abdominal pain following laparotomy. With a large 
number of people, milk ingestion and gas formation are practically 
synonymous. It would seem wise, therefore, to leave the addition 
of milk to the dietary until after the resumption of the bowel 
function, — an effort being made to establish this at the expiration 
of from .48 to 72 hours after the operation. 

4. Bladder Function. — The question of attention to and the 
care of the bladder function is one that is all too apt to be slighted, 
when one considers its importance and the number of different 
ways in which its neglect may cause trouble and confusion to the 
attendants, as well as both these and suffering to the patient. 
There should be no routine resort to the use of the catheter in 
after-treatment. This may seem an extreme statement, but a 
little consideration of the reasons behind it will show, at least, 
the possibility of its importance. With some physicians, it is the 
practice to have the patient catheterized every eight hours after 
the operation until she voids. This custom is rather one of the 
past than of the present, but is one that can still be observed. 
This routine should decidedly not be followed, except in operation 
for the correction of displacements of the uterus, — and the reason 
for the custom in the latter class of cases will be given later. 

The ingestion of liquids for the last eight or twelve hours 
before operation and for several hours after the return from the 
operating room is greatly diminished. From this cause and from 
the effects of the anaesthetic upon the renal secretion, the output 
of urine is greatly diminished during the 24 hours immediately 
following operation. It should, also, be noted that in the ordinary 



218 THE PATIENT 

routine preparation for laparotomy the bladder is catheterized 
just before operation. With the recent catheterization remem- 
bered and the reduced urinary output considered, it is evident 
that there will not, ordinarily, be any call for post-operative 
catheterization until at least 12 (and probably more) hours after 
operation. And an appreciation of the dangers of repeated 
catheterization will make every one hesitate before resorting to a 
measure of this sort unless there are undoubted indications for 
its use. As a rule, then, the catheter should not be called into 
use until at least 12 hours after an operation, and then only in 
the presence of some definite indication and after resorting to 
such measures as we may to encourage the patient to void. The 
indications for the use of the catheter are, of course, a distended 
bladder which must be relieved or as a diagnostic aid in suspected 
suppression of urine. The aids to inducing spontaneous evac- 
uation of the bladder are: (a) the sound of running water, which 
is not infrequently efficacious; (6) the pouring of warm water 
over the vulva, which will sometimes succeed when the preceding 
measure fails; (c) lastly, the administration of an enema, with 
the return of which the bladder is frequently evacuated. If 
these measures fail, it is then time to resort to the use of the 
catheter. Naturally, there are times when it is not desirable to 
use enemata so early after operation, and in such cases it is 
sometimes necessary to use the catheter earlier. 

In operations upon the round ligaments for retrodisplacement 
of the uterus, the weight of the distended bladder upon the uterus 
is to be avoided during the first 24 hours after operation, lest 
the success of the operation be endangered through the strain 
placed upon the transplanted ligaments. In such cases, there 
is no way of avoiding use of the catheter and it is customary,. 
in some hospitals, to have the patient catheterized every eight 
hours after the catheterization on the table for the first 24 hours or 
more. But it must be borne in mind that the catheter demands 
all of the precautions used for any aseptic proceeding that 
involves the entrance into any of the clean cavities of the body. 
An infection of the bladder is a serious matter for both the surgeon 
and patient, and the accompanying danger of an ascending 
infection to the kidneys must be an ever-present bugbear of 
warning to the person bearing the responsibility of the catheteri- 
zation. It is a point upon which there is no possibility of over- 
emphasis and upon which reiteration is perfectly excusable. A 



ROUTINE NURSING IN OPERATIVE CASES 219 

bladder infection, while possibly not the most unusual accident 
of surgical technic and possibly, also, not the most inexcusable, 
is in all probability the most unexcused, with the possible excep- 
tion of an abscess following hypodermic medication. 

5. Bowel Function. — For somewhat the same reasons that 
apply to the bladder function, the bowel function is partially 
inhibited during the first few days following an operation that 
involves manipulation of the abdominal contents. The action of 
the anaesthetic, combined with the handling of the intestines and 
the absence of foodstuffs that have a marked residue, gives the 
double effect of partial paralysis of the intestinal walls and the 
absence of the normal bowel stimuli. There is, therefore, no 
object in the early administration of enemata and cathartics, 
save the possible presence of large quantities of gas. The custom 
has therefore gained common use of refraining from the use of 
any intestinal stimulant during the first two or three days after 
laparotomy, at which time the resumption of the bowel function 
is encouraged by the administration of a simple enema. From 
this time on, if simple enemata are successful, the bowels are 
moved once daily by this measure until the seventh day. Should, 
however, the simple enema prove insufficient to attain the desired 
end, a hypodermic injection of physostigmine salicylate gr. Koand 
strychnine sulphate gr. %o may be given and followed in half an 
hour by a purgative enema. The added stimulating effect of 
this procedure will frequently succeed where the simple enema 
fails. After the seventh day, should the bowels still prove recal- 
citrant, the enemata should be discontinued and some medica- 
ment that has a stimulating effect upon the intestinal muscula- 
ture substituted, — such preparations as the pill of aloin, strychnine 
and belladonna, cascara, or something similar generally proving 
satisfactory. 

6. Opiates. — Only passing mention will be made of this rather 
important problem in operative after-treatment, as the subject 
is one that rests solely in the hands of the attending surgeon and 
can be decided by him only. Opiates are, as would be naturally 
supposed, indicated where the pain is sufficiently severe to re- 
quire attention and the simpler methods prove inadequate. The 
preparations most frequently used are the sulphate of morphine, 
the sulphate or phosphate of codeine and the hydrochloride of 
heroin. These medicaments are generally administered by 
hypodermic injection and in doses up to gr. % f gr. % and gr. Yu, 



220 THE PATIENT 

respectively. Owing to their increased effect upon the intestinal 
paralysis already existing, it is generally accepted that no more 
should be given than is absolutely necessary for the comfort of 
the patient and then discontinued at the earliest possible moment. 
In the limited use occasioned after operation, the question of 
habit formation does not usually come up for consideration. 

7. Dressings. — The question of dressing is one that depends 
upon the suture material used and the condition of the wound. 
Where the wound is clean and absorbable suture material is used, 
there is generally no necessity for dressing the operative wound 
until the fourteenth day. Where non-absorbable suture material 
is used and must be removed, the time for dressing depends upon 
the nature of the material and the method of its use. If the non- 
absorbable suture material is fine silk used as a running skin 
suture, it may be removed from the fifth day on, dependent upon 
the method of closure employed for the rest of the abdominal 
wall. If silkworm-gut through-and-through sutures are used for 
support they should be removed about the tenth day, as they 
have a tendency to cut out and cause considerable irritation and 
discomfort. If a subcuticular silver wire suture is used for skin 
approximation, it should be removed about the fourteenth day. 

8. Sitting Up. — After the average gynaecological laparotomy, 
the patient may be permitted to sit up out of bed for a few minutes 
on from the tenth to the fourteenth day. The custom varies 
considerably with different surgeons, but the above limits may 
be accepted as the early and late limits of the conservative ele- 
ment. In minor cases, such as curettage, trachelorrhaphy, and 
perineorrhaphy, the patient may be permitted to get up anywhere 
from the seventh to the tenth day. It should, however, be under- 
stood that permission to get up out of bed after a laparotomy 
does not convey the idea of a whole day (nor even a half day) 
sitting in a chair. The first venture should not be for more than 
a few minutes, — half an hour at the outside. The next day, the 
length of time may be somewhat increased and repeated in the 
afternoon. By this gradual method, the strength of the patient 
is increased by degrees corresponding to her endurance. If she 
does not feel any fatigue after the first day, the natural inference 
is that she will bear a longer siege on the second day than will 
the patient who is exhausted by a fifteen minutes' seance on the 
first attempt. 

9. Going Home. — If all has gone well from the time of the 



ROUTINE NURSING IN OPERATIVE CASES 221 

operation and there has been no seriously run-down condition 
already existing to make the convalescence protracted, the patient 
may ordinarily be permitted to return to her home at the expira- 
tion of three weeks after the operation. Of course, this period 
is not a definite nor an invariable one. The condition and 
home circumstances of one patient may be such as to make an 
early return desirable, and, in another, quite the contrary may 
be the case. 

10. Belts, Binders and Supports. — The question that is fre- 
quently asked by a patient, following an abdominal operation 
and preceding her return to her home, concerns the advisability 
or necessity of wearing some form of abdominal supporter. In a 
well-nurtured woman, with muscular, firm abdominal walls, the 
use of a support is to be discouraged. If the abdominal walls 
are greatly relaxed and weakened from the extended presence 
of a large tumor or, if there has been infection present that neces- 
sitated the use of prolonged drainage, it may be well to use some 
form of corset or binder that will give the necessary support 
until the walls have regained their natural strength and tone. 



CHAPTER XVII 
POST-OPERATIVE COMPLICATIONS 

No effort will be made to consider this rather extensive subject 
from the view-point of the surgeon, as the diagnosis and treat- 
ment of the different conditions should not devolve upon the 
nurse. An effort will, however, be made to so present the more 
common of these complications that the nurse will get a fair 
picture of the cardinal signs and sjmiptoms in each case, with the 
idea of showing the great importance of accurate charting of 
even the most routine and, apparently, unimportant events. 
The causes, so far as known, will be included in the description, 
in order to promote the intelligent cooperation between physician 
and nurse that is so important for the best interests of the patient. 

I. SHOCK 

The cause of operative (or post-operative) shock is not 
thoroughly understood. The predisposing causes are, however, 
fairly well recognized and accepted. Among the more important 
of these are prolonged anaesthesia ; undue exposure of the patient 
before, during or immediately after operation; excessive handling 
of the viscera; loss of blood; extensive trauma; and severe tox- 
aemia. The occurrence of shock, as might be expected, is also 
influenced by the character and extent of the operative procedure. 

The occurrence may be at any time from during the operation 
to a few hours after the return of the patient to her bed. 

The signs and symptoms are pallor; coolness of the skin sur- 
face, frequently accompanied by cold sweat; fall of the tempera- 
ture, possibly to subnormal; rapid, irregular and weak pulse; 
increased and irregular respirations; more or less mental dulness; 
and a general appearance of some severe crisis. 

II. HEMORRHAGE 

Post-operative hemorrhage (disregarding the classes into 
which it has been divided) is one of the most serious and, fortu- 
nately, most rare of the complications or sequelae with which we 
have to deal. The causes are generally one of three: the failure 
to ligate a severed vessel at the time of operation; the slipping 
222 



POST-OPERATIVE COMPLICATIONS 223 

of a ligature on a tied vessel; or, in the later cases, opening of a 
vessel due to the separation of a slough. The occurrence may 
be at any time during the first week. 

The symptoms may come on suddenly or gradually, dependent 
upon the size of the vessel involved and the lack of interference 
with the flow by surrounding tissues. In the more gradual form 
of hemorrhage, there is a steady increase in the pulse rate with 
a corresponding decrease in volume; the respirations become more 
rapid and shallow; the temperature falls, frequently to subnormal; 
there are pallor, restlessness, precordial distress, dizziness, pain 
at site of hemorrhage and, frequently, fear of approaching death. 

Where the vessel is a large one and there is no interference 
with the flow, the change is sudden and marked. The sharp pain 
(particularly if the hemorrhage is intraperitoneal) is quickly fol- 
lowed by the restlessness, pallor, air-hunger, rapid fluttering 
pulse, precordial distress, fear of impending dissolution and, in 
the end, death. In the latter cases, the patient may have passed 
through the succeeding stages so quickly that death will have 
supervened before the house physician can be summoned. 

III. ACUTE DILATATION OF THE STOMACH 

The onset of this condition is apt to be sudden and alarming. 
Large quantities of fluid, out of all proportion to the amount 
ingested, are vomited. There are frequent eructations of gas. 
And collapse is an early symptom. The temperature is either 
not elevated, or only slightly so. The pulse is rapid and weak. 
The respirations are increased in frequency and often show 
marked dyspnoea. There is distention in the region of the 
stomach, without any visible peristalsis. 

IV. INTESTINAL OBSTRUCTION 

The most common cause of post-operative intestinal obstruc- 
tion is the formation of intestinal adhesions. These may act 
by causing kinking of the intestines or by the formation of bands. 
Other less common post-operative causes are volvulus, hernia and 
intussusception. 

Obstruction of the bowels may occur at any time, from days 
to months after the operation. The symptoms, in the more acute 
forms, are distention; pain; anorexia; nausea; vomiting, the latter 
becoming progressively worse and finally in many cases contain- 
ing fecal matter; increase in rapidity of pulse and respiration, 



224 THE PATIENT 

accompanied by a low and frequently subnormal temperature; 
and inability to move the bowels by enemata. In such cases. 
there is generally early collapse unless the condition is promptly 
relieved by operative measures. 

V. INFECTIONS 

The infections (as the name would indicate) are the result 
of the presence or introduction of pathogenic bacteria. They 
may be either local or general. 

1. The simplest of the local infections is the stitch abscess 
and, after that, the mild wound infection. Of course, the latter 
may vary in degree from a very simple matter to a fairly serious 
one. but. in the general run of cases, it is one of the simplest of 
the post-operative complications. The cause of such infections 
is. necessarily, the introduction of some pathogenic microorgan- 
ism either from within or from without. The staphylococcus 
is the most common organism found in these cases, although 
B. coli communis,. B. pyocyaneus and others are found not 
infrequently. 

The occurrence is generally from the third to the eighth day 
and is accompanied by an elevation of temperature ^102 c to 
103° F.), local pain and tenderness, headache, loss of appetite 
and general discomfort. The symptoms are. in other words, 
those that would be expected to accompany a mild infection. 

2. Sapraemia. — This condition is due to the absorption of 
the products of decomposing tissue which is acted upon by the 
bacteria of putrefaction. The onset is sudden, generally within 
a few hours of the exposure of raw surfaces to absorption from 
decomposing tissues. The symptoms which may arise from a 
few hours to several days after operative or obstetric procedure) 
are a sudden rise of temperature to from 102° to 104° F.. fre- 
quently accompanied by a chill : a rapid and full pulse : increased 
respirations: anorexia: headache: thirst: and. sometimes, nausea. 
The face is flushed: the tongue coated: and the urine is scanty 
and highly colored. 

3. Peritonitis. — Peritonitis may be either local or diffuse. The 
local form may be caused by mechanical, chemical or bacterial 
agents. The symptoms are the same as would be expected in a 
localized inflammation in any other region, with the. symptoms 
peculiar to intra-abdominal affection superimposed. We. there- 
fore, have pain, tenderness, elevation of temperature, increase 



POST-OPERATIVE COMPLICATIONS 225 

of pulse and respiration, anorexia and possibly nausea and 
vomiting. In addition to those, we have abdominal distention, 
general or localized rigidity of the abdominal muscles, sometimes 
a palpable tumor and, probably, either diarrhoea or constipation, 
the latter being more common. 

Diffuse peritonitis is due to the presence of pathogenic micro- 
organisms in the abdominal cavity under conditions that favor 
the extensive spreading of the inflammatory process. These 
conditions may be dependent upon the method of introduction, 
quantity of infectious material, character of the organism or 
reduced resistance of the patient. The onset is gradual, the 
symptoms usually making their appearance from twenty-four to 
forty-eight hours after operation. At first, there is localized pain, 
which afterwards is general throughout the abdomen. This is 
intense in character, accounting for the position generally as- 
sumed by these patients — with the thighs flexed on the body and 
the shoulders elevated in the effort to relieve the tension of the 
abdominal muscles. During the earlier stages, the abdominal 
muscles are contracted — the walls being at times retracted as a 
result. Later there is extreme distention. The respiration is of 
the thoracic type — also as a result of the abdominal tenderness 
and distention — and the tympany marked. A very rapid pulse 
is generally an early symptom, being accompanied by a rise of 
temperature to from 101° to 104° F., which may reach as high 
as 110° shortly before death. The elevation of temperature 
is, however, not constant, as, in rapidly fatal cases, it some- 
times remains practically normal throughout the course of the 
disease. There is early and persistent vomiting, which may, 
during the later stages, become fecal in character. The action 
of the bowels is not constant, either diarrhoea or constipation 
occurring; the latter, however, being the more persistent and 
common symptom. Hiccough is also a very common symptom, 
appearing early in the course of the disease and being persistent 
in character. 

4. Septicaemia. — Septicaemia is a result of the presence of 
bacteria and their products in the blood stream. The most 
common of the organisms found in this condition are the Strepto- 
coccus pyogenes and the Staphylococcus p}^ogenes aureus and 
albus. The symptoms arise in anywhere from a few hours to 
several days, being usually ushered in by an initial chill. There 
is an elevation of temperature to from 103° to 105° F., usually 
15 



THE PATIENT 

with a slight daily remission. The pulse is small and rapid and 
the respirations are usually increased in number in proportion 
to the pulse. The other symptoms are those common to 
all infections: anorexia, nausea, vomiting, scanty and highly- 
colored urine, and. sometimes, diarrhoea. 

5. Pyaemia. — This condition, which is becoming daily more 
rare | particularly : - sequek : operative procedure), may be 
described as septicaemia complicated by the formation of multiple 
abscesses. We have, therefore, the presence of bacteria and their 
products in the blood stream as is the case in septicaemia and. 
further, we have the formation from time to time during the 
progress of the disease of absc sses 7. - grasses may be 
superficial I in which case the condition is apt to be more favor- 
able or they may be located in the most inaccessible regions, as 
the lungs. The condition is usually fatal, except in its mildest 
forms. The symptoms are those of septicaemia, at the beginning, 
but, as the disease progresses, the initial chill is repeated at 
irregular intervals, probably with the formation of new absces 
With each chill there is a following more pi : 1 rise of 

temperature. With the evacuation of the abscess contents 
^either by incision or spontaneous rupture . there is temporary 
improvement in the condition of the patient, to be followed by 
another chill, another rise of temperature and gradually dimin- 
ishing strength as the disease progresses. The duration of the 
condition may be abbreviated where the infection is particularly 
virulent or where the resistance of the patient is already greatly 
ssened by preexisting disease. Usually, however, the course 
is prolonged (sometimes for weeks i. the patient steadily losing 
ground, but having short periods of temporary improvement. 

VI. PULMONARY 

The most common of the pulmonary complications of con- 
valescents from operative measures are lobar and broncho- 
pneumonia. The predisposing causes are a lowered resistance 
from any cause, and undue exposure of the patient before, during 
:*ter the operation. The exciting causes are bacteria and. 

rarely, the inspiration of foreign materials. 
The '_»nset and course of the Lobar form do not materially 
differ from the pure form of the d> se, except ae T he ding: 
may lx- clouded by the other conditions following operation. The 
• pain in the chest, the chill and initial rise of temperature. 



POST-OPERATIVE COMPLICATIONS 227 

the increase of pulse rate with disproportionate increase of 
respiratory rate, the cough and characteristic sputum, and the 
recovery by crisis are all similar, although the onset may be 
missed or confused with other possible sequelae or complications. 
In bronchopneumonia, the onset and course of the disease 
are very much less characteristic and the diagnosis must rest 
upon a careful study of symptoms, the exclusion of other trouble 
and, finally, the findings on physical examination, which, too 
often, are very indefinite. 

VII. URINARY SYSTEM 

There are four conditions of the urinary system that, while 
not confined in their appearance to following operations, do, 
with varying degree of frequency, complicate convalescence. 
These are, in the reverse order of their possible serious import, 
retention of urine; retention with overflow (sometimes called 
"paradoxical incontinence"); incontinence of urine; and sup- 
pression of urine. 

1. Retention of Urine. — Simple retention of urine is a very 
frequent and, usually, a very slight sequela of operations under 
general anaesthesia. The tentative diagnosis is usually made by 
either the nurse or the patient. If the introduction of a catheter 
is rewarded by a free return flow of urine, the diagnosis is, natu- 
rally, confirmed. There are, however, two very real dangers 
associated with this very simple condition, one very remote and 
the other imminent. There is always the possibility, however 
remote, of the overdistended bladder rupturing, with the occur- 
rence of a diffuse peritonitis an almost certain accompaniment. 
There is, besides, the not infrequent occurrence of cystitis (from 
incorrect technic) to be considered and guarded against. 

2. Retention with Overflow. — The dangers of this condition 
are identical with those of the preceding, somewhat increased 
by the possibility of a delayed or mistaken diagnosis of the true 
condition. Here, while in truth an almost complete retention 
is present, there is often sufficient dribbling of urine to give the 
false impression of incontinence. Where the suprapubic area is 
covered by dressings after an abdominal operation, it is some- 
times difficult to determine by examination the presence of an 
overdistended bladder. Where, however, there is the possibility 
of such a condition existing, all doubt may be easily removed by 
the passage of a catheter. 



228 THE PATIENT 

3. Incontinence of Urine (Enuresis). — This condition is not 
a very common one as a sequela of surgical procedure, most fre- 
quently occurring as a result of temporary paralysis of the bladder 
sphincter or actual injury thereto in the course of the operative 
procedure. The constant dribbling of urine or the occasional 
gush as the bladder becomes distended is of itself very distressing 
to the patient, although (if of the simple form) it generally is of 
very short duration. Where the amount of urine discharged in 
the course of several hours is such as to indicate a normal secre- 
tion for that length of time, there is very little room for confusing 
this condition with any other, — retention with overflow being the 
one most nearly resembling it and eliminated by the amount of 
urine discharged. 

4. Suppression of Urine. — This condition (fortunately not a 
very frequent complication of operations) is necessarily serious. 
The failure of a patient to void urine within twelve hours after 
operation should be followed by catheterization for the purpose 
of deciding between the two possibilities of retention or suppres- 
sion of mine. The early diagnosis and prompt institution of 
treatment are essential for the welfare of the patient. 

In summary of the various features that may characterize 
these more common sequelae of operations (more particularly 
abdominal operations), it is evident that a careful charting of 
the subjective symptoms of the patient — the temperature, pulse 
and respiration — so that any marked deviation from their nor- 
mal ratio may be noted; of the absence or presence of nausea, 
vomiting or hiccough; the absence or presence of bowel move- 
ments, with the character of the movement and the fact that gas 
is or is not passed; the voiding or retention of urine, whether the 
former is voluntary or involuntary, profuse or scant and dribbling; 
the presence of cough; and the presence, location and character 
of pain, is a matter of the utmost importance, particularly in 
those conditions where an early diagnosis is practically imperative 
for the welfare of the patient. 



CHAPTER XVIII 

ANOCI-ASSOCIATION 
I. SHOCK AND FEAR 

No one will be inclined to question that great anxiety and 
fear, together with the emotional strain incident to physical 
pain, may have a decided influence upon a patient's fitness to 
meet the ordeal of an operation, and hence become a factor in 
the operative risk, but it is only in very recent years that any 
systematic study has been directed to this subject. That both 
strong emotion and physical injury play an important part in 
causing the condition we know as shock has, of course, always 
been recognized, but our knowledge of the true nature of this 
causal relation was of too vague a character to be of any practical 
use to us in suggesting ways of preventing and treating the condi- 
tion of shock. We have had, in consequence, almost nothing in 
the way of a standardized technic for the management of patients 
with reference to this aspect of our problem. 

We owe to Dr. George Crile a series of experimental and 
clinical researches which throw a wholly new light upon this 
subject. The practical result of these studies has been the devel- 
opment of a new technic in the management of patients who are 
to be operated upon. These new methods have now been in 
actual use in the Lakeside Hospital in Cleveland, Ohio, where 
Dr. Crile is the visiting surgeon, and in a few others for several 
years, and have resulted in a most striking reduction in operative 
mortality and in post-operative morbidity. That part of the 
new method which consists of manipulative measures is quite 
simple and can be easily described. Another and very important 
part, however, which relates to the control of the patient's con- 
tact, mentally, with the conditions which surround him from the 
time an operation is first proposed until it is over and he is re- 
stored to health, cannot be so easily presented in the form of 
exact directions. Here much will depend upon the personality of 
the surgeon and also of the nurse who is in immediate charge of 
the case. The part of the nurse will be of great importance, and 

229 



230 THE PATIENT 

in order that she may enact it well it is necessary for her to under- 
stand as clearly as possible the nature of the problem. 

Let us ask at the outset the question, What are the principal 
physical phenomena attendant upon extreme fright, i.e., the 
symptoms of fear? They are rapid action of the heart, increased 
rate of respiration, pallor of the skin, sweating, dilatation of the 
pupils of the ej^es, muscular relaxation, organic sensations of 
weakness described in common language as a " sinking " feeling, 
and disturbance of the digestive functions. Now let us ask a 
second question of the same kind. What are the symptoms 
caused by severe and prolonged muscular exertion? The answer 
is exactly the same: muscular exertion carried to the point of 
extreme exhaustion gives rise to the same condition in the body 
as does the emotion of fear at its highest intensity. We may now 
ask a third question: Wnat are the synrptoins of shock resulting 
from severe plrysical injury? Again the answer is the same : word 
for word, the answer to the first question will stand for an answer 
to the second or the third. We can, of course, point out minor 
differences, but in all essentials the effects of fear, of exhaustion 
from severe exertion, and of shock from severe injury are identical 
and as a matter of fact one cannot always tell at the first glance 
whether a man is badly scared, or badly hurt, or exhausted from 
overexertion. 

Wherever we find effects so closely corresponding as in these 
cases it is natural and reasonable to assume that the causes 
which produce these effects are also identical. Let us see, there- 
fore, if we can find an3 T common cause at work in each of these 
three widel} 7 different conditions. In what exact way does fear 
cause these phenomena; in what way does muscular exertion 
cause them; how does plrysical injury cause them? Now in the 
second case, that of severe muscular exertion, the answer seems 
obvious enough. It is a case of exhaustion; the muscles have 
done a tremendous amount of work and are, as we say, tired out. 
If we put it in mechanical terms we may say that the muscles 
have used up all the energy-giving substances from which their 
power is derived, and they lose power just as a steam engine does 
when all the coal in its furnaces is burned out, and all the water 
in its boiler is turned into steam. There has been in this case an 
immense draft upon the reserve energy of the body, and. bee 
we are familiar with the idea, it seems natural to us that the 
whole body should share in the exhaustion which follows, and 



ANOCI-ASSOCIATION 231 

it is easy to understand that the nerve-cells of the brain, which 
control and direct the movements of the muscles, should espe- 
cially partake of the effects of muscular exhaustion. 

Now fear and injury both, under natural conditions, produce 
intense muscular effort. For both arouse the instinct of self- 
preservation, which expresses itself in two forms, the impulse to 
fight and the impulse to run away. Perhaps a third form may 
be distinguished in the instinct to struggle when in the actual 
grip of something that hurts. Whichever form the instinct takes, 
great expenditure of muscular energy is called for, with an equal 
expenditure, though one that is silent and invisible, in the cells 
of the brain whose activity drives the motor mechanism. When 
the impulse of flight predominates emotion takes the form of fear. 
With the fighting impulse another emotion appears, that of 
anger, which, when in high intensity, also leads to rapid exhaus- 
tion. In the case of the struggle against anything that hurts, the 
emotion aroused seems to be a blending of the other two. 

Even when the grosser physical manifestations of these emo- 
tions, such as actual flight or struggle, are suppressed, there are 
inner physical effects connected with them, beyond the reach 
of the will, that apparently produce the same exhausting effects. 
Probably, also, the very effort to suppress the more visible 
muscular exertions is itself highly exhausting. In Dr. Crile's 
researches, actual microscopical study in the laboratory of hun- 
dreds of animal and human brains and of thousands of nerve-cells 
has shown changes characteristic of cell exhaustion, resulting 
from each of the three causes, physical exertion, physical injury 
and fear. 

Dr. Crile has also shown that even in an animal anaesthetized 
by ether the impulses received by the brain along the nerves 
leading from the part of the body that is injured bring about 
changes that produce exhaustion in the brain-cells almost as 
severe as if no anaesthetic had been used. When nitrous oxide 
and oxygen was the anaesthetic used, the evidence of exhaustion 
in brain-cells was much less. When a part of the body was com- 
pletely cut off from connection with the brain, as by division of the 
spinal cord, then no amount of injury of this disconnected part 
would cause any appearance of exhaustion in brain-cells or any 
symptoms of shock. We have here then two new facts which 
can be practically applied in the prevention of shock. First, we 
have learned that ether, while it obliterates consciousness, does 



232 THE PATIENT 

not protect the brain from incoming impulses which excite to an 
exhausting waste of energy; while gas-oxygen anaesthesia, on 

the other hand, does protect the brain to some extent. In the 
second place, we now know that if the sensory nerves leading 
from the wounded part can be temporarily blocked i.e.. rendered 
incapable of carrying nerve impulses . as by the infiltration of 
the tissues with a local anaesthetic, then no exciting stimuli will 
reach the brain-cells and there will be no waste of energy and 
no shock. 

Further, the character of an emotion is largely determined 
by memory. Our conscious life from moment to moment is a 
mosaic of remembered things and of new impressions of things 
that are happening. New impressions call up old experiences 
through the association of ideas, and our resulting action and 
emotion will depend upon the character of the associations that 
are aroused. These associations are broadly of two kinds, those 
that suggest beneficial effects (bene-associations) and those that 
suggest harmful effects (noci-associations). The new technic 
involves the avoidance of suggestions or associations of harm. 
and for the description of such a technic Dr. Crile has coined a 
new word — anoci-association. 

II. THE TECHNIC OF ANOCI-ASSOCIATION 

Every major surgical operation, even when the risk is small. 
is an ordeal of so serious a character that few men or women can 
meet it without considerable emotional stress. It is not true. 
of course, that every one who is to be operated on is seriously 
frightened. On the contrary, even' surgeon knows how rare it 
is to see any patient yield to craven fear, and he is an almost 
daily witness of examples of serene and unfaltering courage that 
have never been overmatched upon the field of battle. The 
brave are able to overcome fear and to control their actions in 
spite of it, but they are not therefore exempt from emotional 
stress and the drain which it involves upon the vital forces. In 
ordinary cases this is not perhaps of much importance, but in 
critical cases it may be a decisive factor in the operative hazard. 
There is, therefore, nothing fantastic or visionary in any rational 
attempt to reduce this factor as far as may be possible. That 
every effort should be made to prevent the shock-producing 
effect of actual trauma needs, of course, no argument whatever. 

It is the aim of the anoci-association technic to bring under 



ANOCI-ASSOCIATION 233 

control at every possible point these two factors in the operative 
risk, the harmful effects of emotion and of trauma. It applies 
to the whole period of a patient's surgical experience, from the 
first consultation with the surgeon up to final recovery. This 
period may be divided into four parts: (1) from the first con- 
sultation to the time of entering the hospital; (2) from the 
entrance to the hospital to the beginning of the anaesthetic; 
(3) the anaesthetic, the operation, and the recovery from the 
anaesthetic; (4) the convalescence. There are four critical 
periods when the mind of the patient is particularly susceptible 
to harmful suggestions: (1) the first contact with the surgeon; 
(2) the first entrance to the hospital; (3) the time immediately 
before the operation, when the patient at last comes face to 
face with the dreaded ordeal; (4) the time when consciousness 
returns on recovery from the anaesthetic. 

As Dr. Crile says: "It is only experience and a sympathetic 
understanding of the sensibilities of patients that enables any 
surgeon, at the time of diagnosis and recommendation of opera- 
tion, to reduce to a minimum the first personal contact. The 
pre-operative stay in the hospital can be made least harmful 
by the highest degree of efficiency on the part of the nursing 
and resident staff of the hospital, and by considerate attention 
to the details on the part of the operating surgeon." As to the 
fourth period, "inconsiderate nursing, rough dressings, and 
tactless contacts in the hospital during convalescence" are to 
be avoided. 

The technic at the operation itself can be very briefly sum- 
marized. A small dose of morphine and scopolamine is given 
an hour and a half or two hours before the operation, except, of 
course, in the very young or very old, or in badly handicapped 
patients. Nitrous oxide with oxygen is the anaesthetic employed, 
and it is administered by a trained anaesthetist (preferably a 
woman, in Dr. Crile's opinion). The patient is carefully handled 
and placed on the operating table in proper position to avoid 
back strain, preferably on a warm water bed. The tissues in the 
field of operation are infiltrated with a local anaesthetic solution 
(novocaine 1-400) as completely as if the operation were to be 
done under local anaesthesia only. In abdominal operations the 
area of the peritoneum, which is incised and later sutured, is 
infiltrated with a 1-200 solution of quinine and urea hydro- 
chloride, which has the property of producing local anaesthesia 



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ANOCI-ASSOCIATION 235 

words efficiency and sincerity, is vital for good anoci-association 
work and must receive due consideration. 

The second aspect referred to is particular and personal, since 
it concerns the actual conduct of surgeon and nurses when they 
come in contact with the patient. The prime requisites of right 
conduct from the anoci-association view-point are supreme tact 
and sympathetic understanding of the individual patient. We 
will consider the general aspect first. 

What qualities and what attitude, in the persons into whose 
hands the patient has committed himself in the face of a trying 
ordeal, will make the strongest impression upon his mind in the 
way of encouragement and reassurance? Not sympathy; a 
friendly personal interest and active attention to matters per- 
taining to his comfort and well-being make a strong appeal, of 
course, but sympathy alone is a poor comfort in the presence 
of danger. A passenger on a storm-threatened vessel will be very 
little helped by the knowledge that the captain and other officers 
are exceedingly sorry for him. What he wants to see in these 
men are evidences of disciplined order, keen attention to every 
detail of the situation, and a serene confidence in their ability 
to meet any emergency that can arise. It is the same in the 
hospital; the impressions which the mind of the patient should 
receive are: first, that of a coordinated group of workers (sur- 
geon, anaesthetist, internes, nurses), highly trained, familiar with 
every point in the situation, keenly interested, alertly attentive 
to their several duties, and working together with machine-like 
precision; second, that the whole purpose and attention of this 
disciplined body are for the moment directed to bringing the 
patient's own case to a successful conclusion, with an interest 
in this object as keen as, let us say, that of a crack athletic team 
to win a championship game. 

There is one other impression that the patient should not 
fail to receive, and that is of the absolute certainty in the minds 
of every member of the hospital team that in this particular 
case they are going to win, i.e., as regards the patient's life risk 
in the operation. There is no faking about this. We must win, 
and in order to do this we must be certain of winning beforehand. 
That is the first rule for the players of every game worth while, 
either in the field of sport or in the serious affairs of life. It is the 
doubters who lose, they and sometimes the complacent ones; 
ours, however, must not be the certainty of those who are com- 



236 THE PATIENT 

placent, but the certainty of those who can afford to take no 
chances. 

We have used the words efficiency and sincerity in summing 
up this first or general aspect of anoci-assodation work. Sin- 
cerity in this connection does not mean, of course, the absence of 
a proper reticence still less - _e exercise of a brutal frankness in 
what we say to a patient. What :s ne: .:.: :• -:::_: - :„-. ~ T „ . T 
of shams and a loyalty to the :::,::ti.: 5 interests :_.. : :; r----. : .-- 
and unqualified. 

The consideration of the second aspect, that which relates to 
the management of the individual patient, presents considerable 
difficulties. Few general rules can be laid down. Each patient 
indeed is a separate problem. The reasoning and methods, for 
example, which are applied to a phlegmatic woman from the slums 
will be quite different from those which should be employed in 
the case of a highly-strung, nervous woman accustomed to luxuri- 
ous surroundings . It is in this consideration of each patient as 
an individual that many nurses and doctors f alL It is here that 
the exercise of supreme tact becomes ar. 

anoci-association technic. Tact means touch, here the sensitive 
mental touch in contact with the mind of the patient. A tactful 
person recognizes instinctive^' iz. - .: the nenta! 

"".: ude of another individual —hi: . ~ : :. :.:. life- ~- 

the concealed feelings, as of distrust or antagonism, the suppressed 
emotion, as of fear or hunger for sympathy : - - - 

real or fancied slight. Tactful conduct adapts itself skilfully to 
these subtly perceived conditions and wins its way against all 
resistance, even from the most stubborn personality- It is often 
said that tact is an inborn quality and cannot be acquired. But 
while there is much to justify this view, it may be pointed out 
that tactful cond \. 

of putting oneself in another's place, and this habit, like any other, 
can be cultivated and acquired by determined and sustained 
effort. 

As to sympathy, rightly understood, there can be no question 
of its value and importance. An unsympathetic atmosphere 
begets distrust already been suggested, that 

sympathy ►mmiseration or compassion is of little 

use in guarding the patient from those harmful associations which 
we wk So is doubtless soothing to a 

tortured mind, but it carries no suggestion of security; it sugg 



ANOCI-ASSOCIATION 237 

if anything, the contrary. Sympathy that is effective and helpful 
is not emotional but intellectual; its office is to understand, not 
to commiserate; its purpose is to bring the person who is its 
object, by the light of a clearer knowledge, to a view-point cor- 
responding to its own. If the object aimed at is to be attained, 
our sympathetic understanding must have such an effect upon 
the patient's mind as to make it share in our feeling of confidence 
in the methods which we employ and our own certainty in the 
good result. 

Both before and after entering the hospital the patient's con- 
tact with friends and acquaintances is a source of noci-associations 
which is to a large extent beyond our control. Some people, 
because of ignorance and prejudice, are almost incredibly brutal 
and tactless in what they say to a patient. On the other hand, 
these friends are often our most helpful supporters in bringing a 
patient to operation in a cheerful and confident attitude of mind. 
Within the hospital the patient's contact with other patients 
may be the means of arousing the emotion of fear. In the free 
wards of a hospital (the male wards part cularly) the patients 
who have already been operated on sometimes take a mischievous 
delight in initiating the newcomers with hair-raising accounts 
of their own experiences. The nurse may have better opportuni- 
ties than the surgeon to learn of and counteract the hurtful sug- 
gestions from both these sources. Patients who have passed the 
ordeal can do much to help us if we can secure their interest and 
cooperation. Proper hospital discipline and tactful management 
on the part of nurses, internes and surgeon can do much to avert 
harmful contacts of the patient with friends or other patients. 

With regard to definite rules of conduct, only a few suggestions 
of a general character can be given. The first is not to talk too 
much. The nurse should say as little as possible and volunteer 
nothing at all about operative risks. In the first place, it is the 
duty of the surgeon to impart the knowledge to which the patient 
is entitled in regard to the quality of danger that is to be en- 
countered, and all such questions should be referred to him for 
an answer. In the second place, overanxiety in insisting upon the 
absence of danger may have an effect quite opposite from that 
intended. Mere optimistic assurances carry little weight with 
patients, who are apt to regard these as perfunctory and possibly 
insincere. On the other hand, the nurse need not hesitate, when 
questioned, to give free expression to her own confidence that 



2SS THE PATIENT 

the result will be good derived from her personal experience 
and observation and from a just pride in the achievements of the 
organization in which she is a unit. In doing this, however, it 
is best to avoid all reference to anatomical or operative technical 
details. The methods of surgery can, as a rule, have only a 
morbid interest for one who lacks the training needed to see 
them in their proper setting as a means to an end, and they are 
full of possibilities of harmful suggestions to the patient. Perhaps 
the most difficult achievement in conduct will be found in main- 
taining such a proper reticence without veering from the straight 
path of sincerity and truth. To deceive a patient deliberately 
ie rither right nor fair play nor justifiable on grounds of expedi- 
ency; for if once a suspicion of being deceived, or that knowledge 
of important matters is being withheld, has found lodgement, it 
will be very difficult to regain the confidence that has been lost. 
Sometimes, indeed, the impulse of a great compassion may lead 
one to give comforting assurances without strict regard to the 
truth, but this practice should never become a rule of conduct. 
Moreover, since a reticence that is too obvious may have the 
appearance of insincerity, it is probably better that all discussion 
of grewsome details or other distressing matters should be frankly 
forbidden rather than that shifty attempts at evasion be made 
in response to the patients , questions about them. At all times 
every effort should be made to keep the brighter side of the 
picture in the focus of attention. 

The moment when consciousness returns after reaction from 
anaesthesia has been mentioned as one of the critical periods of 
emotional stress. Although recovery from nitrous oxide and 
oxygen anaesthesia is far more rapid than from ether, in neither 
case, of course, does consciousness return all at once. Reeovery 
progre— zes, the higher mental faculties concerned 

in the exercise of reason and will being the latest to awaken, and 
meantime all the harmful associations that have been so carefully 
silenced and controlled may return with unrestricted sway. 

re the heavy eyelids can open the mind gropes blindly in 
the dark for the broken threads of memory, and the first recall 
of the actual situation, like the sudden remembering of a great 
trouble on waking from sleep, is apt to come with a shock that 
brings potent suggestions of uncertainty and doubt as to the 

: of the operation with a corresponding emotional strain. 
The preliminary dose of morphine and scopolamine has an un- 



ANOCI-ASSOCIATION 239 

doubted calming influence upon the patient both at the beginning 
of the operation and at the time of the recovery from the anaes- 
thetic. The effect of these drugs is to inhibit emotion and mem- 
ory, but this does not, of course, alter the psychic situation at the 
sudden recollection of a dreaded ordeal, with its attendant pos- 
sibilities of arousing the emotion of fear. When full consciousness 
returns the patient is apt to ask repeated questions about the 
operation and to be not very easily convinced that all is as it 
should be. Since it is almost invariably a nurse who is with the 
patient at this time, upon her devolves the duty of giving the 
assurances needed to dispel the harmful associations that may 
arise, and it is important for her to know how this may best be 
done. With regard to this point Dr. Crile has suggested a method 
which is of unique interest and value. 

It appears at first glance like utterly ridiculous folly even to 
try to think of a way to tide an unconscious patient over this 
crisis. What wizardry can we conjure up to control the mind 
in sleep? Yet the method of doing this is very simple and almost 
invariably successful. 

In sleep all paths by which knowledge reaches us from the 
outer world are obstructed, but not all equally so. Vision is 
wholly cut off. We are blind in sleep, the eye cannot receive 
and convey any message whatever to the brain. Not so the ear; 
except in the profoundest sleep this avenue between the brain 
and the world without is never wholly blocked. Our dreams, as 
every one knows, are often affected and controlled by sounds 
that do not waken us. A sleeper may even make what appear 
to be intelligent movements in response to spoken commands 
and have no recollection of so doing when he wakes. It is through 
the ear, therefore, and through this avenue alone, that we can 
reach the anaesthetized patient, before consciousness returns, 
with a message of comfort and reassurance. 

At the first sign that the patient is passing from profound 
unconsciousness into the borderland of sleep, a change in the 
respiratory rhythm, or a movement of the head or hand, a quiet, 
assured voice speaks clearly into her ear, " The operation is 
over and everything is all right/' Again and again, through the 
slow struggle up out of the dark, the voice repeats its message, 
always in clear, deliberate tones and with the simplest phrasing. 
It ceases when the eyes first open with a conscious look. 

The contrast of such an awakening with that we have just 



240 THE PATIENT 

described is curiously interesting. When full consciousness re- 
turns, the patient's expression is not one of pitiful anxiety and 
doubt, but rather one of immense relief. Often she appears 
quite happy and contented. She asks no questions; she feels no 
need of asking, for she knows that the dreaded ordeal is over 
and that all is well. How this knowledge came to her she can- 
not tell you and will be puzzled for a moment if you ask her, 
but not troubled with any shadow of doubt. Absolute convic- 
tion is in her mind, a certainty like that of intuitive knowledge, 
and she accepts it gladly and without question. 

Miss Florence Henderson, anaesthetist at the Mayo Clinic, 
uses the same method of verbal suggestion at the beginning of 
the administration of an anaesthetic. She points out that, 
B Suggestion plays an important part in the induction of anaes- 
thesia." And, u The assurance of the anaesthetist, when the 
patient is in the subconscious state, that he is all right and that 
nothing will be done until he is unconscious, aids markedly. 
The mind is very susceptible to suggestion in this state, and the 
suggestion that even-thing is as it should be is usually accepted." 

In Dr. Crile's clinic at the Lakeside Hospital the introduction 
of the anoci-association technic has been followed by a reduction 
in the surgical mortality from 4.8 per cent, to 1.7 per cent. The 
diminution of post-operative discomfort has been especially 
notable. 

Finally, it should be pointed out that whatever disagreement 
there may be among surgeons as to the value of the operative 
technic advocated by Dr. Crile, the use of nitrous oxide anaes- 
thesia, and of a combination of local and general anaesthesia, 
there is no disagreement at all about the importance of the 
general principle of anoci-association; and as Dr. Bloodgood has 
said, we cannot safely reserve our application of this technic for 
the more serious cases. The master}* of any technic can only 
be acquired by incessant practice, and we must employ this one 
in all cases or else we shall fail with it in the critical ones where 
the need for it is imperative. With surgeons and nurses alike 
the application of the principle of anoci-association should be- 
come a fixed habit or second nature in the personal management 
of all patients, no matter how trivial the c. 



PART V— THE OPERATION 



CHAPTER XIX 

THE OPERATING ROOM, ITS OUTFIT AND SUPPLIES 
I. THE OPERATING-ROOM ORGANIZATION 

The operating department in every hospital is apt to be a 
subject of special pride with every one connected with it. There 
is perhaps some danger that this very proper feeling may con- 
cern itself too much with the imposing but comparatively unim- 
portant material aspects of the equipment, and too little with the 
real essentials ; namely, efficient organization, conscientious exact- 
ness in every small detail of the technic, and good team work at 
the operation itself. The spotless white walls and floors, the 
glittering glass furniture, the polished battery of sterilizers, the 
neat array of shining instruments, the many ingenious devices 
for various purposes, — all these make an attractive picture, but 
they furnish in themselves little or no evidence as to the actual 
quality of the work that is being done in the department. The 
whole object, both of the equipment and the organization, is to 
safeguard the patient from the operative dangers, and the attain- 
ment of this end depends not upon the showy outfit but upon the 
spirit and efficiency of the workers themselves. 

The details of the operating-room organization vary consider- 
ably in different institutions. The persons essentially concerned 
with the work of the operating room maybe enumerated as follows : 

(1) Surgeons of the Attending Staff, the Resident Surgeon, 
and sometimes other surgeons not connected with the institution, 
who operate there on their private patients. 

(2) Assistants, usually the hospital internes. In hospitals 
which have the " open door " (that is, where outside surgeons 
are allowed to operate on their own patients), the surgeons may 
sometimes bring their own assistants with them. Usually a first 
and a second assistant are required at each major operation. 

(3) Anaesthetists. These are, as a rule, graduates in medicine 
who have specialized in this field. They are appointed and paid 
by the institution and are responsible for all the anaesthetics given 
there. They give to the internes, and sometimes to graduate 
nurses who desire to fit themselves for this work, systematic 
instruction in the administration of anaesthetics. Some surgeons 

243 



244 THE OPERATION 

of wide experience are of the opinion that women make the best 
anaesthetists, and there is reason to believe that this may become 
eventually, to some extent at least, one of the nursing specialties. 

(4) The operating-room nurse has entire charge of the operat- 
ing rooms. She is responsible for the care of the rooms and 
equipment, the preparation and sterilization of the various 
materials used in an operation, and the training of the pupil 
nurses assigned to work in the operating room. The position of 
operating-room nurse is a permanent one and is usually filled 
by a graduate nurse who has had special training and experience 
in the work. 

(5) Senior assistant nurses who have had a month or more 
of experience in the operating room. In a very active service, 
where several operations are going on at the same time in different 
rooms, there should be a senior assistant nurse in immediate 
charge of each separate operating room, acting under the direc- 
tion of the operating-room nurse. 

(6) Other pupil nurses assigned to the operating room for a 
definite period during the course of their training. 

(7) Operating-room orderlies, who do the heavy work, such 
as lifting the patients, cleaning the rooms and such special duties 
as may properly be assigned to them. 

It is, of course, the surgeon himself who is chiefly responsible 
for the results of his operations, but these results depend alwa}*s 
in large measure upon the quality of the preparatory technic, 
and in many operating rooms a number of surgeons operate, 
some of whom, at least, have little or no authority over the oper- 
ating-room organization. It is, therefore, upon the operating- 
room nurse that the weight of responsibility rests for efficient 
operating-room administration, and it is in man}' cases chiefly 
from her that the inspiration comes for those who work under 
her direction. Her position is one of the most important in the 
surgical department of any hospital and is, or should be, one of 
the chief prizes of the nursing profession. Efficiency in operating 
organization is shown by a perfect and absolutely reliable pre- 
paratory technic; by the absence of vexatious delays in the 
preparation between one operation and another that is to follow 
it; and by the prompt supply of such needs as may suddenly 
arise in an emergency during an operation. The final mark of 
efficiency is what may be called good team work at the operation 
itself, by which is meant that each person does his own part at 



OPERATING ROOM: OUTFIT AND SUPPLIES 



245 




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OPERATING ROOM: OUTFIT AND SUPPLIES 



247 



operating rooms; there need rarely be more than three or four 
except in the largest institutions. The essential features of a 
good operating room are ample space, abundant north light, 
floors, walls and ceilings finished with some material that is 
smooth, non-porous, and water-proof, and absence of crevices 
or corners from which it is difficult to remove dust. In the other 




Fig. 81. — Hot-air sterilizer. 

rooms size and light are less important, but all should be so 
arranged as to be easily cleaned. 

III. THE OPERATING-ROOM FIXTURES 

These comprise the arrangements for heating and for arti- 
ficial lighting; the plumbing fixtures, including basins and sinks; 
the closets and the steam connections for the various sterilizers; 
the lockers in the dressing rooms, and the lockers and shelving 
in the supply room; and finally the sterilizers. 

1. The Hot=air Sterilizer. — This is much used in the labora- 
tory for the sterilization of glassware and other apparatus (Fig. 81). 
It is not usually a part of the furniture of the operating room. 
It consists of a double-walled chamber or oven with a door, 



248 



THE OPERATION 




Fig. 82. — Autoclave. 



and a strong gas flame underneath so arranged that the heat 
enters between the double walls. 

2. The Autoclave (Figs. 82-83).— This is also a double-walled 
chamber with a door, but the door is made to fit air tight, and to 



OPERATING ROOM: OUTFIT AND SUPPLIES 249 







the :: i~.-.. 



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OPERATING ROOM: OUTFIT AND SUPPLIES 



251 



sible to give specific instructions here. A failure to employ this 
apparatus properly means a failure in one of the most important 
parts of the aseptic technic. Moreover, the danger of careless 
handling of high-pressure steam sterilizers should always be 
remembered. 




Fig. 85. — Utensil sterilizer. 

3. The Instrument Sterilizer (Fig. 84). — This is a simple 
metal container of suitable size and shape in which water can 
be boiled. Heat may be applied by means of gas or of steam from 
the boiler-room. 

4. The Utensil Sterilizer (Fig. 85) . — This is a larger apparatus 
similar to the instrument sterilizer, used to sterilize basins and 
other large objects by boiling water. 



252 



THE OPERATION 




Fig. 86. — Water sterilizers. 



OPERATING ROOM: OUTFIT AND SUPPLIES 



253 



5. Water Sterilizers (Fig. 86). — These are large tanks in 
which water is sterilized by means of steam coils. Two tanks 
are provided in order that both hot and cold sterile water may 
be available at all times. 

The basins for hand washing are so arranged that the hot 
or cold water can be turned on or off, without touching anything 
with the hands, by means of levers acted on by pressure with 




-Operating table. 

the foot or knee, the mixture of hot and cold water being delivered 
through a single goose-necked spigot at any desired temperature, 
so that the hands can be washed in a running stream. 

The doctors' dressing rooms are provided with a sufficient 
number of lockers with individual keys. The supply room is 
fitted with lockers and shelving with glass doors for the storage 
of supplies. The operating-room nurse should have a master 
key fitting all the locks. 



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to absolute essentials. A table for instruments and 
a stand or support for the drums containing the sterfli 
ings (Fig. 88) „ basins set in stands for hand-rinsing 

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OPERATING ROOM: OUTFIT AND SUPPLIES 255 

The utensils needed consist of a number of glass or enamelled 
ware dishes and basins of suitable sizes and shapes for holding 
the various solutions used in the surgical toilet, and for the 
reception of pus or other fluid evacuations, of specimens removed 
at the operation and of soiled sponges and dressings. As adjuncts 
to the operating table itself a pad or mattress will be required 
for the patient to lie on, preferably of 
rubber and distended with air, in any case 
rubber covered; also both hard and soft 
cushions in several shapes and sizes to sup- 
port the patient's head and other parts 
of his body as occasion may require. At 
times the surgeon will need a stool to sit 
on and at other times a footstool to stand 
on for convenience in some special manip- 
ulation. Infusion of fluid into the rectum 
and of normal salt solution under the skin 
or into a vein may be required in the treat- 
ment of shock during an operation. The 
apparatus required for this purpose is 
known as an irrigator stand (Fig. 89) and 
consists of a glass receptacle for the fluid, 
preferably graduated, having an opening 
at the bottom to which five or six feet of 
rubber tubing is attached. The other end 
of this is armed with a suitable nozzle 
or hollow needle. The glass irrigator is 
supported on a stand arranged so that it 
can be raised or lowered to any desired 
level. Since it may be called for at any 
time on short notice in an emergency, the 
irrigator with its tubing and needles should 
always be sterilized and ready for instant 

use at every major operation. A rack FlG " 89 -- Irri * ator stand - 
with a definite number of hooks on which to hang the gauze pads 
that have been used in an abdominal operation is considered an 
essential piece of furniture in many operating rooms. It is useful 
to make sure that the pads are properly counted, in order that 
none may be accidentally left in the abdominal cavity. The 
other rooms of the operating suite will be almost bare of furniture. 
Space must be found, preferably in a separate room, for one or 




256 THE OPERATION 

more instrument cabinets, made of glass and iron, -with glass 
doors and shelves on which the instruments are arranged in order; 
also for a glass and iron shelf rack on which bottles and jars con- 
taining various materials used in operative work may be placed. 
For the rest a few glass-topped tables and enamelled iron chairs 
or stools are all that is permissible. 

T. TEE OPERATING-ROOM SUPPLIES 

The description of surgical instruments, of the methods of 
preparing the various materials used in the course of an opera- 
tion, such as sutures, ligatures and dressings, and the preparation 
and uses of the different solutions employed are subjects too 
extensive to be included here and must be reserved for separate 
consideration. 

To begin with the articles required for the surgical toilet, the 
first is soap. It is probable that the selection of the particular 
kind to be used is not a matter of very great importance. The 
requisites are active cleansing powers and freedom from irritating 
properties. The finer toilet soaps fall short in the former respect 
and the stronger kitchen or scouring soaps are too irritating to 
the skin. The official green soap of the pharmacopoeia is most 
connnonly used. It must be diluted with boiling water for the 
double purpose of reducing it to the requisite thinness and lessen- 
ing its irritating properties. In some operating rooms, a hard 
soap containing pumice is used. Perhaps one of the best is the 
Schleich marble-dust soap, the formula for which is given in 
another chapter. Brushes are usually employed in hand cleans- 
ing, but are often objectionable on account of the injury their 
constant use inflicts upon a delicate skin. Thorough scrubbing 
with a piece of soft gauze is equally efficient and far less irritating. 
The use of anything that tends to roughen the skin of the hands 
of one who takes part in an operation is an error in technic. Nail 
cleaners with sharp points or edges are to be avoided; and also 
any solution to whose irritating properties there is found to be 
an individual susceptibility. 

operating-room dress for men consists of a two-piece suit 
of fight-weight cotton material for which the street clothing is 
exchanged. Over this a rubber apron is worn, and over all the 
operating-room gown. A close-fitting cap of cotton material 
cover? the hair. The mouth and nose are covered with a mask 
to prevent droplet infection when talking near the wound. The 



OPERATING ROOM: OUTFIT AND SUPPLIES 257 

simplest form of mask consists of six thicknesses of gauze sewed 
into a square, four and a half inches on the side, with tapes at the 
corners to tie round the head and neck. Special shoes for the 
operating room may be of canvas or leather, according to indi- 
vidual preference. Rubber gloves, into the gauntlet of which 
the sleeves of the gown are tucked, complete the toilet. Buttons 
are troublesome, since they come off in the laundry. Draw-strings, 
tapes and safety pins are preferable as fasteners. The gowns open 
at the back and are fastened with tapes; they reach below the 
knee and are best made with detachable sleeves reaching from 
above the elbow, so that only the sleeves need be changed between 
clean operations. In passing from an infected to a clean case 
the whole gown must be changed, and this must be done also in 
passing from one clean case to another if detachable sleeves are 
not used. The two-piece suits are freshly laundered for each day, 
but not sterilized. The use of freshly laundered caps, not steril- 
ized, is not a serious break in technic. Rubber aprons must be 
sterilized after use in operating on an infected case. Gowns, 
sleeves, masks, and gloves must be freshly sterilized for each 
operation, with the exception, already noted, as to the gown. For 
women the gown will be of suitable pattern and made reaching 
to the feet. The caps must be more voluminous and fastened 
with draw-strings to secure them over the hair. Gowns for 
visitors are sleeveless, made like a long cape to cover hands and 
arms. A sufficient number of these various garments of suitable 
sizes is kept on hand and a freshly laundered supply always 
ready. Rubber gloves of at least three sizes must be provided. 
A glove that is too tight becomes painful after being worn for an 
hour or two, and one that is too loose is a source of awkwardness. 
Some surgeons have gloves manufactured for their individual 
use over moulds made from plaster casts of their own hands, 
insuring a perfect fit. Gloves are easily torn or punctured at an 
operation. When this occurs the punctured glove must be at 
once discarded and a fresh one put on. A glove so injured can 
be easily patched with a piece cut from an old glove and applied 
over the defect with rubber cement. 

For the protection of the patient on the operating table, the 
materials required are blankets, rubber sheeting, sheets and 
towels. Of the sheets and, particularly, the towels, a very 
abundant supply is necessary. The so-called laparotomy sheet 
is a plain sheet with an opening fourteen inches long in the centre 
17 



258 THE OPERATION 

of the sheet. The upper end of the opening is eighteen inches 
from the top hem of the sheet. The edges of the opening are 
hemmed. The sheet covens :he patient's whole body from the 
neck to the feet, the field of operation being exposed through the 
opening in the centre of the sheet. The gynaecological, perineal 
or lithotomy sheet is made in the form of two loose bags shaped 
to cover the patient's feet and legs when in the lithotomy posi- 
tion. The remaining portion of the sheet covers :he lower part 
of the abdomen and the perineum. A twelve-inch slit exposes 
the field of operation. 

Besides the rubber gloves, sheeting and aprons already de- 
scribed, there are a number of other articles made of rubber 
which find a place among the operating-room supplies. Kelly 
pads are placed under the patient's thighs when in the lithotomy 
position: rubber tubing in several sizes is used for many purposes; 
a roller bandage made of pure rubber is known as the Esmarch 
bandage and is used to compress a limb for the purpose of con- 
trolling hemorrhage. For the same purpose is the rubber tourni- 
quet, a piece of elastic tubing with a chain and hook attack- 
fasten it after it is in position. This should always be applied 
over several thicknesses of toweling wrapped smoothly about 
the limb. These articles, together with rubber catheters, stomach 
tubes and rectal tubes, should perhaps be classed with the instru- 
mental outfit. To prevent deterioration all articles made of 
rubber should be kept dry, dusted with talcum powder and at an 
even temperature. Extreme cold and heat, or marked changes 
of temperature, and particularly any oily substance, cause rapid 
deterioration of rubber. 

Glassware in a variety of forms will be required, including 
measuring glasses or graduates, holding 10 c.c, 100 c.c. and 1000 
c.c; bottles and jars for containing chemicals: and empty bottles 
and jars for specimens. Glass tubing in various sizes and forms 
is used for many purposes : for irrigator nozzles, to connect rub- 
ber tubing, for drainage tubes and for female catheters. Medicine 
glasses and drinking glasses will be often needed. Medicine 
droppers, eye droppers and glass syringes of different sizes will 
be occasionally called for. The graduated glass irrigators have 
already been described. Large and small laboratory flasks of 
thin glass which can be sterilized will be needed for normal salt 
solution. Trays and small dishes far various purposes, g 38 
rods and microscopic slides and test tubes should be included 



OPERATING ROOM: OUTFIT AND SUPPLIES 259 

in the outfit. A few test tubes plugged with cotton and sterilized 
and others containing culture media for making bacterial cultures 
should always be at hand. 

A rather long list of drugs and chemicals will be kept in stock. 
Those in crystalline or powdered form will include: bichloride 
of mercury, boracic acid, permanganate of potash, oxalic acid, 
iodoform, iodine, bismuth subnitrate, carbonate of soda, bicar- 
bonate of soda, oxide of zinc, salicylic acid, common salt, silver 
nitrate, novocaine. Solutions of some of these, of appropriate 
formula?, will be kept in stock, and others will be made up as 
required. Plaster-of -Paris and talcum powder will also be needed. 

In tablet form or in sterile solution in sealed glass ampoules 
for hypodermic use in suitable doses there will be needed: mor- 
phia, atropia, strychnia, pituitrin, cocaine, epinephrin (adrena- 
lin), strophanthin, novocaine, quinine and urea hydrochloride, 
caffeine and sodium-benzoate. Combination tablets of some of 
these and a sufficient variety of doses of each of them will be 
required. The list of drugs in liquid form will include: alcohol, 
carbolic acid, benzine, tincture of iodine, balsam of Peru, aro- 
matic ammonia, ether, glycerine, hydrogen peroxide, collodion, 
olive oil, whiskey, amyl nitrite (in "pearls"), ammonia water, 
rubber cement. In semiliquid form vaseline, green soap, glycerite 
of starch, bone wax and various ointments should be at hand. 

Suppositories containing opium and certain astringent drugs 
are frequently used after operations on the rectum. It is, of 
course, impossible to enumerate all the special formulae that are 
used in different institutions. 

Of the various woven fabrics included in the operating-room 
supplies, the most important item is the so-called absorbent or 
hospital gauze. There will be several grades of this, some of 
very loose weave for absorbent dressings, some of closer weave 
for use in making such articles as masks, abdominal packs and 
roller bandages. Unbleached muslin will be used for making 
covers for dressing material when being sterilized, retractors 
used in amputations, roller bandages and a number of special 
forms of binders and bandages. Crinoline is used for plaster-of- 
Paris bandages and for the so-called starch bandage. Cotton 
fibre is employed in several forms. The ordinary cotton wadding 
of commerce has comparatively few uses in the operating room. 
It is non-absorbent because of the oily substance which it con- 
tains. A piece of it cannot be made to sink in water. It is some- 



260 THE OPERATION 

times used where elastic pressure is desired under a firm bandage. 
Absorbent cotton is the same material from which all the oil 
has been abstracted. A piece of it should instantly sink to the 
bottom when dropped into water. Hospital wadding is non- 
absorbent cotton made in the form of sheets glazed on both 
sides. It is used to cushion splints and to pad limbs under a 
plaster-of-Paris bandage. A thick felt, such as harness makers 
use, is employed to protect bony prominences where a carefully 
fitted plaster splint or jacket is applied. 

A number of miscellaneous articles, some of them of great 
importance, remain to be mentioned. Adhesive plaster is em- 
ployed to fix dressings over a wound and has an astonishing 
variet} r of other uses. The Z. 0. (zinc oxide) plaster is least 
irritating to the skin. The so-called " Janus " plaster, faced on 
both sides with adhesive material, is useful to prevent bandages 
from slipping. Gutta-percha tissue is employed almost uni- 
versally for protecting wound surfaces and for wrapping gauze 
drains. Silver foil is used in many operating rooms as a wound 
dressing, particularly after skin grafting. 

A full supply of material for splints should be on hand in the 
operating room. The number of special forms of splints on the 
market is too large to be described in detail. The forms of splint 
material most generally useful are the splints of woven wire 
which can be cut and bent to any desired size and shape and the 
splints made of thin, soft wood. A form of wooden splinting of 
the thinness of veneer is useful to incorporate in dressings where 
a firm, even pressure or a certain degree of rigidity is desired. 
It comes in pieces three by eighteen inches. Larger and heavier 
splints of wood one-eighth inch in thickness are supplied which 
can be cut to any size or shape desired. 



CHAPTER XX 

OPERATING MATERIAL 
I. CLASSIFICATION 

A considerable part of the nurse's time, during her course 
of training in the operating room, will be taken up with the 
preparation of the various materials employed in the course of 
the operation itself and to cover and protect the wound after 
the operation until the completion of the healing process. This 
work of preparation is of fundamental importance for the surgical 
technic, and it is necessary to describe it with some exactness. 
It must be remembered, however, that the practice in different 
institutions in the preparation of operating material varies con- 
siderably in minor points, and that the methods given here are 
not to be regarded as in any sense exclusive, for the form in 
which these materials are made up is largely a matter of personal 
preference with the surgeon, and no two workers will ever agree 
exactly as to what methods and means are the best. What we 
shall attempt to do in this chapter is to make clear the purpose 
for which these articles are used and to describe some of the 
methods of preparing them that are of proved efficiency. 

The things which ordinarily come in temporary contact with 
the wounded tissues in the course of an operation are (1) the 
gloved hands of the surgeon and his assistants, (2) the instru- 
ments which he employs, (3) pieces of absorbent gauze or cotton 
made up into convenient shapes and sizes. These latter articles 
serve three distinct purposes: (1) to keep the wound " dry" 
(that is, to soak up blood, pus or other fluid which tends to fill 
the wound and obscure the surgeon's view of the field of opera- 
tion) ; (2) to push to one side any tissue or organ that tends to 
get in the surgeon's way and hold it there for the time so that it 
will not obstruct his view or his work ; (3) to protect surrounding 
parts from contamination with septic material when a localized 
infection is being dealt with. 

Any one of these things (gloves, instruments, gauze) may 
become a source of infection in a clean wound by conveying 
septic bacteria into it, as a result of imperfect methods of sterili- 
zation or of carelessness in handling them after sterilization, and 

261 



262 THE OPERATION" 

when this occurs we speak of it as " contact infection." There 
are other materials which come in contact with the wounded 
tissues and remain in contact with them until the first dressing, 
or for a longer time, or even permanently. The most important 
members of this class are drains, sutures and ligatures. When 
infection from any of these possible sources occurs it is known 
implantation infection." 

Materials used to cover and protect the wound are known 
as dressings, and are put up in a great variety of forms. The}" 
are usually made of absorbent gauze, although cotton and occa- 
sionally other materials are also used. These dressings are also 
possible but less dangerous sources of wound infection. 

Other articles, such as adhesive straps, bandages and binders, 
serve the purpose of holding the dressings in place. These need 
not be sterilized, but they must, of course, be fresh and clean. 

II. MATERIALS WHICH COME INTO TEMPORARY CONTACT 
WITH THE WOUND 

1. Sponges. — Sea sponges were used in operations in the 
pre-aseptic era, but had to be discarded because they could not 
be kept clean. The name is retained for the pieces of gauze or 
cotton that are now used for the same purpose. 

Large crushed sponges are made of gauze 18 inches square. 
The raw edges are tucked under and the gauze crushed with the 
hand. 

Small crushed sponges are made of gauze 9 inches square 
prepared in the same way. These latter are used as stick sponges 
or u sponges on a stick," by which is meant that the sponge is 
caught by the blades of a long-handled clamp and used to sponge 
out the bottom of a deep cavity. 

A very convenient form of sponge is the folded strip sponge. 
It is made from a piece of gauze 18 inches long and 10 inches 
wide. One end should be selvage or folded in one inch to secure 
an end free from ravels. The gauze is folded lengthwise, bringing 
each long edge to the centre of the piece. It is then folded once 
again lengthwise. This gives a strip of folded gauze 17 inches 
long and 2}4, inches wide, with no raw edge except at one end; 
this end is held between the left thumb and index finger; the 
index, middle and ring fingers are placed together closely, the 
strip is wrapped about the three fingers up to within two inches 
of the selvage edge; and the end is folded down diagonally toward 



OPERATING MATERIAL 263 

the tips of the fingers and tucked under the roll. The sponges 
are used in this form at the operation and can also be quickly 
unrolled when a long, narrow strip is needed to sponge out a 
deep cavity. 

A small wad of cotton wrapped in a three-inch piece of gauze 
and tied with thread is a useful and economical form for use in 
free sponging or on a stick. 

Small pledgets of cotton rolled into balls are desirable in 
some operations on the brain where the tissues must be handled 
very delicately. 

2. Packers or Laparotomy Sponges. — These are also known 
as tape sponges. They are used in operations within the abdomen 
to keep the intestines out of the way and to protect them. 

Large tape sponges are made as follows. Cut the gauze 
from the bolt in fifty-inch lengths. Use the full width of the 
gauze doubled once lengthwise. Turn the ends in one inch to 
secure smooth edges; bring the ends together and sew across top 
and sides; at one corner sew a ten-inch length of tape, preferably 
black in color. This gives a strip of four thicknesses of folded 
gauze, free from raw edges, twenty-five inches long and eighteen 
inches wide. This size is very convenient to pack off intestines 
during the removal of large tumors. The tape is kept outside 
the abdominal cavity and fastened with a clamp at its free end 
to prevent its being accidentally left in the abdomen. The safe- 
guards against this inexcusable happening cannot be too numer- 
ous or too carefully adhered to, for it is surprisingly easy to over- 
look even a large sponge in the abdominal cavity. 

Medium tape packers are made from twenty-four inch lengths 
of gauze. After turning raw edges in one inch at each end, the 
gauze (already doubled once on bolt) is folded lengthwise in 
three folds; the ends and side are sewed, and a tape is sewed to 
one corner. This gives a strip of six thicknesses of gauze six 
inches wide and twenty-two inches long. Three smaller sizes 
of packers are made in a similar manner to measure when finished 
six by six inches, four by four inches, and two and a half inches 
by two and a half inches. The smallest size is not often used, 
but is very convenient at certain times. At the Mayo clinic 
three sizes of packs are used, (1) 4 x 8 inches, (2) 5 inches by 3 
yards, (3) 3 inches by 2 feet. The latter are used for packing 
about the gall-bladder. All are made of eight thicknesses of 
gauze, with hemmed edge and tape at the corner. 



264 THE OPERATION 

3. Retractors or retractor bandages are used in amputations 
to hold the skin and muscle flaps out of the way while the bone 
is being divided with the saw. They are made of two thicknesses 
of unbleached muslin, twenty inches long and eight inches wide. 
The bandage is split for two-thirds of its length into either two 
or three tails and the edges stitched together. The two-tailed 
form is used in amputations of the upper arm or thigh and the 
three-tailed form for amputations of the forearm or leg where 
there are two bones to be divided. 

III. MATERIALS WHICH ARE TO REMAIN IN THE WOUND 
FOR A TIME OR PERMANENTLY 

1. Sutures are stitches used to hold the divided tissues 
together so that they may heal in the proper position. All 
sutures except those uniting the skin or mucous membrane remain 
permanently in the wound. Skin stitches are usually removed 
at the first dressing on the fourth to the ninth day after the opera- 
tion. When each stitch is tied separately and the threads cut 
short the suture is called an interrupted suture. A continuous 
suture is one where the tissues are sewn together in the ordinary 
way with a long thread and only the first and last stitches are 
tied. Deep or buried sutures are those which are taken in any 
of the tissues under the skin. Sutures are of two kinds as regards 
the material of which they are composed: (1) those made of 
thread or wire which will remain permanently in the tissues or 
(when in the skin or mucous membrane) will be cut and removed 
at a later time, and (2) those made from animal substances 
which will hold the tissues in place while the healing process is 
going on and then will become gradually absorbed. For the latter 
class of sutures and ligatures two different materials are employed. 
(1) Catgut, so-called, is the same material that is used for violin 
strings, except that for surgical uses much smaller sizes are 
selected. It is made from the fibrous coat of the intestines of 
sheep cut into strips and twisted. The word catgut is supposed 
to be a corruption of " kitgut," kit being an old name for a small 
violin. (2) The material known as kangaroo tendon consists 
of strands of varying thickness separated from the strong tendi- 
nous bundles found in the tail of the kangaroo. 

The sterilization of these materials presents a problem of 
peculiar difficulty. The strength and pliability of sutures de- 
rived from animal tissues are rapidly destroyed under the influence 



OPERATING MATERIAL 265 

of high temperature applied in the ordinary way. Catgut, from 
the nature of its origin, is almost certain to have embedded in 
its strands some of the bacteria contained in the intestinal canal, 
and among these are not infrequently found, particularly in the 
domestic animals, the spores of anthrax and tetanus bacilli, 
which are highly resistant to every method of sterilization. Cat- 
gut was doubtless sometimes the cause of infection in wounds in 
the early days of its use, owing to the crude methods employed 
in its preparation, and it may become a source of danger even 
now through lack of proper care or the use of an imperfect method 
of sterilization. At the present time we have available a number 
of processes whereby catgut can with certainty be made sterile 
without impairing its desirable qualities. Some of these are 
described below. The most reliable methods are, however, so 
difficult and exacting that many institutions prefer to purchase 
their catgut prepared and sterilized ready for use from commercial 
houses which make a specialty of this work. The catgut and 
kangaroo tendon supplied by these firms come in small coils of 
convenient size placed in glass tubes with alcohol and hermeti- 
cally sealed. When this prepared catgut is used the only further 
preparation necessary is to sterilize the outside of the tube by 
boiling with the instruments. The tubes are scratched with a 
file to facilitate breaking. To break a tube the instrument nurse 
wraps it in sterile gauze and bends it in a direction away from the 
file mark. The alcohol in the tube serves the double purpose 
of acting as a preserving fluid and of demonstrating that the 
tube is actually sealed. A small crack in. a tube, or 'an almost 
invisible opening sometimes left at the point of sealing, may 
escape notice, but if either is present the alcohol will rapidly 
evaporate, and such a dry tube must always be discarded. 

The materials for non-absorbable sutures are thread, wire 
(of silver or other metal), the so-called silkworm-gut, and horse- 
hair. Thread used for sutures is either silk or linen, usually 
dyed black, although white silk and linen in the natural color 
are much used. The finest size compatible with sufficient strength 
is to be preferred. For ordinary use No. A to No. C black sewing 
machine twist or surgeons' iron dyed silk (No. 2), and tight 
twisted, iron-black Irish linen (Nos. 25, 35, and 50) are suitable. 
Linen thread impregnated with celloidin to make it non-permeable 
is known as Pagenstecher's linen. The thread; whether silk or 
linen, is cut into two-yard lengths, wound on glass spools and 






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OPERATING MATERIAL 267 

to the technic, but it may be well to state briefly the objections 
to the use of catgut, in order to emphasize the necessity of care 
in its preparation. The objections as summarized by Dr. Halsted 
are " the relatively high cost of catgut, its bulkiness, the incon- 
veniences attending its use and sterilization, its inadequacy, the 
uncertainty as to the time required for its absorption, and the 
reaction which it excites in the wound." Catgut, particularly 
in the larger sizes, is a source of slight but distinct irritation in a 
wound. The best manufacturers very properly urge that sur- 
geons should use by preference smaller sizes than now commonly 
employed. This irritating property is doubtless responsible 
for the fact that few now use catgut for skin stitches. As stated 
above, catgut is thought by many surgeons to be an unsafe 
ligature material for large arteries, since the bite of the tie may 
become loosened by softening and stretching of the strand, and 
an ordinary double knot is apt to slip. The absorption of catgut 
is accomplished through the dissolving action of ferments in the 
tissue juices and by phagocytosis, and this process is a slow one. 
In cases reoperated on, a catgut knot may often be found still 
unabsorbed weeks or months after it was put in place. With an 
aseptic technic that is up to the proper standard no trouble 
need be feared from silk or linen sutures and ligatures. 

3. Methods of Preparing Catgut. — If only the surface of a 
strand of catgut needed to be sterilized the problem would be a 
comparatively simple one, but unfortunately in the process of 
manufacture septic and other bacteria are quite certain to become 
embedded in the centre of the strand and may there retain their 
vitality for a considerable time. The most serious, although 
fortunately not a very frequent, danger arises from the presence 
of spores of the tetanus bacillus. This organism is commonly 
found in the intestinal contents of the domestic animals, including 
the sheep, and there is always a possibility that catgut may 
contain its spores. The method of sterilization must, therefore, 
be sufficient to destroy with certainty this most resistant organ- 
ism. Of the several methods of sterilization previously described 
it is obvious, in the first place, that we are debarred from the 
use of one, namely, moist heat in any form, since this will so 
soften and weaken the catgut as to render it useless. There is, 
however, a partial exception to this in the case of catgut hardened 
in formalin. 

Chemicals in watery solution are unavailable for the same 



__> THE OPERATION* 

:n. and the strand is found to be exceedingly resistant to 
alcoholic solutions, so that bacteria embedded in the centre of 
the thicker strands will remain unaffected, even after immersion 
for a long time in an alcoholic solution of a powerful disinfectant. 
A long strand of catgut so prepared may be placed in culture 
media and incubated at a suitable temperature for some days 
without any growth resulting, but if the same strand be cut into 
quarter-inch lengths an abundant growth will follow. This fact 
h - oeen repeatedly demonstrated in the case of catgut prepared 
:i- i .line solution at the laboratory- of the ^Michael Reese Hospital. 
'.-: —ous chsinfectants will not. of course, penetrate a catgut 
strand. There remains, therefore, only dry heat to be considered, 
and for this a much higher temperature is required than in the 

of moist heat; 150° C. or 302 r F. for one hour is the mini- 
mum requirement for sterilization by dry heat. Xow moist 
heat means not heat in any liquid but heat in the presence of 
water. Dry heat means not heat in dry air necessarily but heat 
in the absence of water. Boiling in alcohol, therefore, is an 
application of dry heat. The boiling point of alcohol in the open 
air is 170° F. Alcohol boiled under fifteen pounds pressure in the 
steam sterilizer may give, at the most, a temperature of 250" F.. 
far below the requisite point. For the proper application of 
dry heat, therefore, we need some material which will not affect 
the catgut and which has a boiling point sufficiently high to allow 
a temperature of 300° F. to be reached. This is accomplished 
by the use of some of the oily hydrocarbons. Two of the methods 
here given are based on this principle. 

Two varieties of catgut are used, known as " plain " and 
'■ chromicized.' 7 The latter has been chemically treated by a 
process similar to one of the methods used in tanning leather, the 
object being to cause delay in the pro ss bsorption. Thus 
the manufacturers will furnish u ten." " twenty." or " thirty 
day " catgut. The rate of absorption varies, however, with the 
character of the tissues in which the catgut is used. Absorption 
in skin and muscv is g \ in serous or mucous membranes it is 

mely rapid. The preparation of plain catgut, preliminary 
to its sterilization, consists in immersion in ether for several days 
and then in alcohol, the object being to remove any fatty material 
that may be present, for this, if allowed to remain, tends to weaken 
the catgut under the influence of a high temperature. Chromi- 
cized catgut has been first treated with ether and alcohol as above 



OPERATING MATERIAL 269 

and then placed in a solution of bichromate of potash, six grains 
to the pint of 95 per cent, alcohol, or in a 4 per cent, aqueous 
solution of chromic acid for twenty-four to thirty-six hours. 

First Method. — Dry heat (method of Reverdin). The catgut 
is cut into eighteen- to thirty-inch lengths and made into coils 
about the size of a silver quarter. The coils are strung on an 
asbestos thread and suspended in a double-walled oven in such a 
manner that they do not come in contact with the metallic walls 
or floor of the oven. The temperature is gradually raised, 
through a period of several hours, until it reaches 150° C (302° F.), 
and maintained at that level for one hour. Close attention is 
necessary in carrying out this method, or the catgut is likely to 
be brittle. At least two hours should be consumed in gradually 
raising the temperature to the desired point. 

Second Method. — Dry heat sterilization in cumol (Kronig's 
method). On the first day the coils are placed in the dry oven 
in the manner already described and the temperature gradually 
raised to 116° C. (240° F.) and maintained at that level for one 
hour. On the second day the strands are immersed in cumol and 
heated very gradually up to 155° C. (310° F.), at which tempera- 
ture they are kept for two hours. An asbestos-lined kettle is 
used. An iron basin filled with dry sand is placed over a powerful 
gas flame and the kettle partly embedded in the sand. On the 
third day the cumol is removed and the dry-heat process is 
repeated exactly as on the first day. On the fourth day the 
coils are immersed in alcohol and heated in the steam sterilizer 
under 25 pounds pressure for one hour. On the fifth day the 
fourth-day process is again repeated. This is essentially the 
method employed by the manufacturers, except that the coils 
are placed in glass tubes at the beginning of the process and 
these are filled with alcohol and sealed in the blow-pipe flame 
at the end of the third day's sterilization. 

Third Method. — Dry heat sterilization in alboline (method of 
Dr. Willard Bartlett). The preliminary preparation and the 
first day's sterilization are exactly the same as described under 
the first method. The coils are then placed in an asbestos-lined 
kettle containing liquid alboline. They are left immersed in the 
alboline in a warm place for twenty-four hours, or until the 
strands become semitranslucent. The second and in this case 
final sterilization is done by heating over a sand bath as described 
under the second method. Heat is applied gradually until at 



THZ yPERATKSR 

the en an n ■ half the temperature of the aiboline 

ached '.'-.' 7 .--' Ube bBBMpaafam if - ma _ _ ^ined for 

^t i n 7__ - . ;:_ - the process. The gut > stored in a 

me percent ; lution in alcohol. This should be contained 

arge-mouthed gl^-- jau witih ground glass stopper. The ©oils 

U _- :: . :_ the hot aiboline with a sterile 

unenl Ihe itself -hould be proxided with a closely 

::::i, ?ovez :«f rietsl : . " ! 7 bo protect the 

nd the whole steriliz- ry heat at L r > ! : J 

- GDf — -_ die solution. The coils should 

be d: ... nc n rinsed in ~_t am aniotin» before 

Hie fi| : I h - ■ . i should be wiped wifh 
dk bi 41 ri e mge whenever kite ^topper h fa be taken 
out for the puip: — : removing with i sterile instalment -_ T 
: -_ ..- m *_. - ■ 
Fourth Meti — I inc sterifisalian method :: Claudius). 
Ihe soils iffta the prefanmaiy ■awi n nation are simply imme: - 
in a 1 per Dent somtioii .: iodine in ilcohol. They rcma in 
man-:.', m thk - hriion md must have been subje:- 
for two week- 7 bis i n --_. in use in 

man- .■ ;t:ons. It b open to suspicion from the theoretical 

stand-point. -.--_ — --_ experience in practice seems to 

show tha~ Dei siaes :>f catgut at least; for 

the large: : ly unsafe 

- ndcnm:; sterilizec in the - .me manner as 

. ". I snotstan the _igh temperate: - - - ~elL 

4. Drain? — laced in infected wounds to p: 

-imetimes in Tery extensive dean 
wou: : timulation of bio - rum in the wound. 

- 1~ ay- 
In infected woul :_ ain usually for a longer * 

glass 1 ubing, rubber tnbing. 

-pereha tissue, or the so-called rubber 

dam used in s ipply glass drains 

and shapes and of properly annealed glass so 

- - f may not i •:- ■ easily Bn a tube drains are 

mad Eromf _ 

n diameter, and i inches long. Side holes 

-.•metimes split lengt: 

drain is 
made of rubber tubing wrapped fit- rveral layers of gauze 



OPERATING MATERIAL 271 

and then with gutta-percha tissue. A " cigarette" drain or 
''wick" is made from a strip of gauze wrapped with gutta-percha 
tissue or rubber dam. One end of the strip, free from ravellings, 
should extend beyond the gutta-percha wrapping for about half 
an inch. Another form is made from a square of gutta-percha 
tissue placed between two single thicknesses of gauze and rolled. 
A folded strip of gutta-percha tissue or several strands of some 
ligature material twisted together will sometimes be called for 
when a very small drain is required. Glass and rubber are 
sterilized by boiling : gutta-percha tissue melts at a low tempera- 
ture and must be sterilized by storing in 1-1000 bichloride solu- 
tion. These drains are usually made up as needed at the operating 
table. For drainage of the gall-bladder a rubber tube of 3^-inch 
lumen, about 14 to 18 inches long, will be needed. The tube is 
" dressed " at one end with selvage gauze and gutta-percha 
tissue, and will be fitted over a glass connection tube at the other 
end with which to attach it to a longer tube at the bedside. 

5. Medicated Gauzes. — Gauzes impregnated with iodoform 
and other chemical substances are still in use to some extent. 
They are a survival of the antiseptic as distinguished from the 
present aseptic era in surgery, and their use is becoming more 
and more limited. They are still used in drains to some extent, 
and to pack in septic wounds. The formulae for these gauzes 
are given elsewhere. 

6. Other materials are occasionally buried in a wound to 
accomplish various purposes. Horseley's bone wax is used to 
check hemorrhage in bone, steel plates and screws to fix fractures, 
the Murphy button in making an intestinal anastomosis, and so 
on. Most of these belong rather to the instrumental outfit than 
to the classes of operative material to be prepared by the nurse 
which are under consideration in this chapter. 

IV. WOUND DRESSINGS 

1. Gauze. — The forms and sizes in which gauze dressings are 
put up vary considerably in different institutions. It is not 
claimed that those presented here are superior to others. They 
may serve as types of the various forms of dressings in use. 

(1) Fluffs are made of three-quarters of a yard of gauze cut 
from the bolt, opened out singly, the raw edges turned in and 
crushed in the hand. In use they are shaken out and arranged 



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OPERATING MATERIAL 273 

ized in a muslin wrapper or in a large glass tube, plugged as in 
the case of the uterine gauze. 

(8) Rectal Plug. A large dressed tube wound with gauze to 
the thickness of one inch and covered with vaseline or protective 
is used in the rectum, after hemorrhoid operations. 

(9) Silver foil as a dressing material for wounds is used to 
cover the lips of the wound before the gauze dressings are applied. 
It comes laid between sheets of thin tissue paper sewed together 
at one edge in the form of a book. The sewed edge is trimmed off 
with scissors and the package is then placed between two pieces 
of thick binding board, wrapped with muslin and sterilized in 
the steam sterilizer. 

2. Gutta=percha tissue, designated usually as " protective," 
is made from the dried sap of a tropical tree. Its principal com- 
mercial use is as an insulating material, particularly in the manu- 
facture of ocean cables. In surgery it is employed in the form 
of thin sheets as a protective covering for wounds, and in making 
cigarette drains. Immersion in bichloride solution is the only 
practical means of sterilizing it. 

3. Crepe lisse, or fine silk bolting cloth, is sometimes used, 
fixed to the skin with collodion, to draw together the lips of 
small wounds. Fine batiste, gauze or silk, dipped in celloidin, 
may be used to protect wider areas of the skin in the neighbor- 
hood of a wound. A coarse linen net impregnated with celloidin 
is recommended for fixing and holding skin grafts in place. 
These materials are sterilized and are cut to suitable sizes for 
each individual case at the time they are used. 

V. MATERIALS FOR THE FIXATION OF WOUND DRESSINGS 

Strips of adhesive plaster two or three inches wide are uni- 
versally employed to fix dressings in place over abdominal 
wounds particularly, but also in many other situations. The 
plaster is not sterilized and may or may not be covered with a 
binder or roller. 

Roller bandages are made from one to six inches in width 
and ten yards long. The material is unbleached muslin or gauze 
of a tighter weave than that used for dressings, usually thirty 
to forty threads to the inch. Four inches is the widest muslin 
bandage that can be advantageously used. It is a convenience 
and an economy to use wider gauze bandages (six inches) in 
18 



274 THE OPERATION 

fixing large dressings in the operating room. The bandages are 
not usually sterilized except for special cases. The supply of 
roller bandages in the several sizes should be abundant. The 
method of preparing them is described in another chapter. 

The abdominal binder is a broad belt, made to encircle the 
abdomen, overlapping in front and to be fastened with safety 
pins. It is made of a single or double thickness of unbleached 
muslin, and in a number of sizes. Standard sizes are 14 inches 
by 1 yard, 16 by 40 inches, 16 by 46 inches. 

The scultetus or many-tailed bandage is an abdominal binder 
of which each end is divided into six or eight tails, leaving a 
solid piece at the back about ten or twelve inches wide. 

A better form is made of four strips, each seven inches wide, 
the top three 46 inches and the lowest 50 inches long. These 
are laid together so that each strip overlaps the one above it by 
one-half its width, and sewed securely throughout the middle 
twelve inches, thus leaving four tails at each end. The advantage 
of this binder is that it can be made to fit very smoothly over the 
abdomen. A sufficient number of safety pins must be used to 
secure all the loose ends. 

The T-bandage is used to fix perineal, vulvar or rectal dress- 
ings in place. It consists of a four-inch belt with one or two 
strips three inches wide sewed to its middle at right angles to 
it. This bandage can be readily improvised from strips of suitable 
length taken from a four-inch muslin roller. 

VI. METHODS OF ASSEMBLING AND STERILIZING OPERATING 

MATERIAL 

Sponges and, particularly, abdominal packs must be put up 
for sterilization in packages each containing a definite number, 
so that strict account of them can be kept, in order to guard 
against the possibility of one of these articles being left in the 
abdominal cavity. The covers in which the goods are wrapped 
are made of heavy unbleached muslin doubled and stitched 
together. The towels are put up in packs one dozen or one-half 
dozen in each. Each sheet and gown is placed in a separate 
package. Single packages of gauze dressings of every kind should 
be kept on hand, put up, for example, as follows: fluffs and pads, 
one dozen in each package; gauze rolls, one or two in each pack- 
age; large crushed sponges, one dozen in each package; stick 
sponges and folded sponges, two dozen in each package; tape 



OPERATING MATERIAL 275 

packers, one-half dozen in each package. These are only illus- 
trative, the practice varying in every point in different operating 
rooms. The essential thing is to have an established and definite 
system. It is well to have a plan whereby the responsibility can 
be fixed for errors in counting. For example, sponges and packers 
may be counted separately by two nurses whose names, on a 
slip of paper, are included in each package. 

The Operating Unit Package. — Large packages containing 
everything necessary for a particular operation are prepared and 
put up either in large muslin wrappers or in metal drums manu- 
factured for the purpose. These drums are 12 inches in diameter 
and 9 to 12 inches high. The drum is pierced with a row of holes 
around the circumference at the top and bottom. A sliding 
band with corresponding holes enables these to be opened or 
closed at will. The openings are for the purpose of enabling the 
steam to penetrate to the contents of the drum, and are closed 
when the drum is taken from the sterilizer. When ready for 
use the drum is placed on a stand so arranged that the cover 
may be lifted by means of a foot lever (Fig. 88). For example, 
the laparotomy package or drum may contain 18 towels, 1 lapa- 
rotomy sheet, 1 small sheet, 2 large, 4 medium and 2 small 
packers, 2 packages of sponges, 2 of fluffs, 2 of large pads, a small 
wad of cotton for application of iodine, etc., 4 gowns, 1 binder. 
There will, of course, be more or less variation in the make-up 
of these packages in different operating rooms. 

Sutures and Ligatures.— The preparation of these for ordinary 
use has already been described. Special methods of assembling 
the sutures used in operating upon the intestines and upon 
arteries and veins are usually employed. 

For intestinal sutures fine silk or linen is cut into fourteen- 
inch lengths and threaded on No. 7 milliner's needles. These 
are then basted, in parallel lines about half an inch apart, into 
strips of muslin or small towels, one-half dozen in each. The 
strips are then folded, enclosed in muslin wrappers, and sterilized 
in the steam sterilizer. The thread must be fastened, either by 
tying into the eye of the needle with a single knot about two 
inches from one end, or better by transfixing the thread with 
the point of the needle, two inches from the end, and drawing 
the perforated thread down to the eye. This fastens the thread 
without adding the bulk of a knot. These threaded needles, as 
they are called, are also much used in ordinary work, including 



276 



THE OPERATION 



the suturing of the skin. Small, curved, round needles may be 
used in place of the straight needles by those who prefer them. 

Operations involving the suturing of large arteries and veins, 
so as to preserve the continuity of the circulation, present a 
problem in technic of very great difficulty on account of the 
tendency of the blood to clot wherever the walls of the vessels 
have been injured, and the danger of leakage due to the powerful 
pressure of the arterial blood 
stream. The methods for such 
suturing have been developed 
in recent years to a high degree 
of perfection, but their use re- 
quires great skill on the part 
of the surgeon, attainable only 
by careful practice, which is best 
secured by experimental work on 
the lower animals. 

Straight needles threaded with 
silk are used, both of a degree of 
fineness not obtainable through 
ordinary commercial channels, 
and they must be prepared in 





Fig. 90. — Needle and thread 
for suture mounted and ready for 
sterilization (Bernheim). 



Fig. 91. — Flask containing liquid vase- 
line and four mounted needles for arterial 
suture. Sterilized and kept as stock. 



a special manner. The Kirby needles (made for lace makers) 
Nos. 16, 17 or 18, with Alsace thread No. 500, were originally 
recommended by Carrel for this purpose. No. 00000 (five naught) 
silk, furnished by Belding Bros. & Co. of New York, and No. 12 
ground down needles, made by H. Milward and Sons, are recom- 
mended in a recent work by Bernheim. For the preparation of 
arterial sutures the technic given by Bernheim may be accepted 



OPERATING MATERIAL 277 

as standard. The special fine silk is cut into twelve-inch lengths, 
threaded into the tiny Kirby or Milward needles and the ends 
drawn even. The thread is not tied or fixed in the eye of the 
needle. The needle is pinned into a small piece of writing paper 
about Y2 mcn by 1 inch in size (Fig. 90) , and the doubled thread 
wound about the needle in a figure-of-eight, the ends being caught 
in a slit in one corner of the paper. Four needles so threaded are 
placed in a small flask containing two ounces of liquid vaseline 
(Fig. 91), which is plugged with cotton and capped with gauze, and 
sterilized in the ordinary way in the steam sterilizer. At the opera- 
tion the flask is emptied into a dry sterile medicine glass placed on 
the operating table. The sutures are not to be touched by the 
instrument nurse, but handled only by the operator. Two or 
more sterile medicine droppers, with fine points, are provided 
to be used for washing out, with normal salt solution and liquid 
vaseline, the blood-vessels where the sutures are being applied. 



CHAPTER XXI 

SURGICAL INSTRUMENTS 

The nurse who enters, for the first time, upon operating- 
room duty is likely to experience a sense of strangeness and con- 
fusion far surpassing any that she may have known in other 
branches of her work. Not only is the work itself unfamiliar 
to her, but the very utensils and instruments are frequently 
unknown to her even by name, and much less so by use. The 
effort of this chapter will be to familiarize the nurse not only 
with the names and appearances of the more common instruments 
but also with the grouping in which they occur in different opera- 
tions and the order in which they may be demanded during the 
different successive steps of these operations. It is hoped that 
this discussion will render easier the recognition and selection 
of the different instruments when called for and, also, the proper 
arrangement and prompt delivery of instruments during opera- 
tions. 

It may be stated, in general terms, that every operation (not 
solely manipulative in character) calls for the use of five general 
classes of instruments : cutting, clamping, holding, exposing, and 
sewing. Each of these classes must, necessarily, include many 
different varieties to suit the particular demands of the region 
and nature of the particular operation. An effort will be made 
to give a general description of the different instruments occurring 
in each class, the more definite and accurate description being 
left to the illustrations. 

1. Cutting Instruments. — These are, broadly speaking, knives 
and scissors (Fig. 92) for work in the soft tissues and drills, 
trephines (Fig. 93), curettes (Fig. 94), cutting forceps (Fig. 95), 
chisels (Fig. 96) and saws (Fig. 97) for work in bony tissue. The 
knives may again be divided into three main classes: scalpels, 
bistouries and amputating knives. The scalpel is a small, straight 
knife, with the blade and handle generally made of one piece 
of metal, and the blade flat, convex towards the edge and consti- 
tuting from one-third to one-fifth of the total length of the knife. 
The bistoury is very similar, except for a lighter, narrower blade, 
which may vary greatly in shape with the purpose for which 
278 



SURGICAL INSTRUMENTS 



279 



destined. The amputating knife is a much larger and more 
formidable looking instrument. The blade is apt to be nine 
inches, or even more, in length, possibly double-edged, and the 
handle only sufficiently large to furnish an efficient grip to the 
hand. It is scarcely necessary, or indeed possible, to describe 
the scissors. The general character is known to all and the 
different varieties are legion. It is sufficient to say that surgical 




Fig. 92. — Cutting instruments: knives and scissors. (1) Scalpels; (2) tenotomy knives; 
(3) bistouries, straight and curved, sharp and blunt ; (4) amputating knives— Liston's, Catling 
(double edge); (5) scissors, sharp and dull points; (6) Littauer's suture scissors; (7) Lister's 
bandage scissors; (8) Emmet's uterine scissors; (9) Mayo scissors; (10) "American" um- 
bilical scissors. 

scissors vary in type from the very small (adapted to the most 
delicate work) to the heavy, scissors-like, bone-cutting forceps 
that are capable of cutting through a rib. 

The drills used in bone-work vary in size from one small 
enough to make a hole for the passage of moderately fine silver 
wire to the heavy, burr-tipped drill now largely used to supplant 
the old circular saw (or trephine) in cranial operations. The 
saws, also, vary largely, both as to size and shape. The trephine 



SURGICAL INSTRUMENTS 



281 




282 



THE OPERATION 




Fig. 97. — Cutting instruments: bone saws. (1, 2) Metacarpal saws; (3) metacarpal saw 
Gifting back) ; (4) Satterlee's saw; (5) Hey's skull saw; (6) GigU's wire saw. (For bow type 
of saw see Fig. 129.) 

(mentioned above) is nothing more than a ring of metal with a 
saw edge, used for removing a circular button of bone from the 
skull in intracranial operations. The Gigli saw is a pliable wire, 
roughened so as to more resemble a file than a saw and used for 



SURGICAL INSTRUMENTS 283 

work where the instrument can be passed around the bone to 
be cut and the work done through a small aperture with minimum 
danger to the soft tissues. Bone-cutting forceps are generally 
fairly heavy instruments, built on the scissors principle and with 
strong cutting edges, which may be either straight or curved to 
resemble a scoop. A curette is merely a metal scoop with a 
handle sufficiently substantial to furnish a good grip. It might 
be mentioned that the use of the curettes is not confined to bony 
tissue, one of the most marked exceptions being the long-handled 
curette used for scraping the uterus. 

2. Clamping Instruments (Figs. 98-101). — These instruments 
may be described, in general terms, as any planned for the 
temporary control of the escape of fluid from its containing part. 
The reason for the very broad limits of this definition will, per- 
haps, be better appreciated when the extremely broad applica- 
tion of this type of instrument is understood. The principle of 
construction is very nearly related to that of the scissors so far 
as appearances go. The difference lies in the absence of a cutting 
edge; the close approximation, under pressure, of the flattened 
blades, when closed; and a catch locking device near the ends of 
the handles. As would be supposed, the most common type and 
use of this instrument is for the temporary prevention or control 
of hemorrhage. The different instruments vary in size from com- 
paratively small ones designed for the seizure and control of a 
single bleeding vessel to the quite heavy ones, expected to grasp 
a large section of tissue (possibly containing several large vessels) 
and prevent the possibility of bleeding. Any particular instru- 
ment of this type may, of course, be applied to a small opening 
in a tumor containing fluid or even in the bladder, for the purpose 
of temporarily preventing the escape of septic material into the 
abdominal cavity. Another large class of clamping instruments 
is designed for operations upon the digestive tract. The blades 
(Fig. 101) of these are longer, more springy and less rigid and gen- 
erally covered with rubber tubing to prevent permanent injury 
to the delicate gut. A third group is designed for temporary 
control of the circulation in operations upon the vascular system. 

3. Holding Instruments (Figs. 102-103). — It must be ac- 
knowledged that this class of instruments is scarcely a distinct 
entity in itself, as instruments designed for other purposes (par- 
ticularly those of the clamping type) are frequently made use of 
in this connection. There is, however, one broad class here 



THE OPERATION 

Fig. 9a Fig. 99. 






Fig. 100. Fig. 101. 



p IG gg — Clamping instruments: haemostatic clamps. (1) Kocher - ; mos- 

i UciLaaer's. 
—Clamping instruments. (1) v oa Blunk's; (2, 3, 4 s ) Pean'a; (5) Kelsey 3 hemor- 

Flfiu 10O.-^-Clamping instruments, fl) Kelly- Murphy; (2) Pean's "T" clamp; (3) 

j-.t clamp: " • 'urved clamp. 

101 — Clamping instruments. (1,21 Intestinal clamps; (3,4) stomach clamps (1, 
Wri?.: - :iayo-Rob^. 

included and, in addition to that, numerous auxiliaries that have 
„>bject. The prominent general class of holding instruments 



Fig. 102. 




Fig. 103. 

Fig. 102. — Holding instruments. (1) Halsted's mouse-toothed forceps; (2,3) dressing 
forceps; (4) tongue holding forceps (Houze's); (5) bone clamps (Holden's); (6) Ferguson's 
lion-jaw bone-holding forceps; (7) sequestrum forceps (Van Buren's) ; (8) Doyen's tissue- 
holding forceps; (9) tenaculum. 

Fig. 103. — Holding instruments. (1) Richter's volsellum forceps; (2) Skeene's volsel- 
lum forceps; (3) Emmet's; (4) Foerster's sponge or dressing forceps; (5) Richter's; (6) 
Collins 's uterus holding forceps. 



256 



THE OPERATION 




F:v 104 
Volkm arm's;; (2) 



Exposing instruments: retractors. (1) Sharp hook retractors (Simon's, 
Halsted's: (3j Kelly's; (4) Richardson's; (5) Langenbeck s; (6> Freer's 



re:r*::s: : . 



is that of the dissecting forceps Tig. 102. Xos. 1. 2 and 3 . 
These are otherwise variously described as tissue forceps, or 
thumb forceps. The names "dissecting."' or '"tissue."' forceps are 
somewhat descriptive of their use. They are really the left hand 



SURGICAL INSTRUMENTS 



287 



of the operator. They closely resemble large tweezers in appear- 
ance and, with them, the operator grasps and steadies the tissues 
immediately under his attention, using them for the thousand 
and one purposes for which the fingers of the left hand would 
ordinarily be called into play were they not too slippery and cum- 
bersome for delicate work. These instruments are generally de- 
scribed as smooth or mouse-tooth (or even rat-tooth, or merely 
tooth) forceps, according to whether the grasping tip is or is not 
armed with teeth to make a more secure hold possible. They 



Fig. 105. 



Fig. 106. 




Fig. 105. — Exposing instruments: retractors. (1) Kelly's; (2) Langenbeck's; (3) Doyen's; 
(4) Jackson's; (5) Young's vesical (bladder) retractor. 
Fig. 106. — Exposing instruments: retractors. (1, 2, 3) Young's; (4) Simpson-Mayo. 



are made comparatively short for work on the surface or in easily 
accessible localities and twelve inches or more in length for work 
in less accessible cavities. In addition to this class, brief mention 
may be made of such instruments as tongue-holding forceps (Fig. 
102, No. 4), for seizing and making traction on the tongue; and 
the numerous forceps of the clamp type designed for the proper 
seizure and exposure of the uterus in gynaecological operations. 
The latter instruments are known as single or double tenaculum 
forceps (Fig. 103, No. 2), volsellum forceps (Fig. 96, Nos. 1 



288 



THE OPERATION 




SURGICAL INSTRUMENTS 



289 



and 5) and uterine elevating forceps, according to whether the 
grasp is rendered secure by a single, unopposed fine point; two 
opposed fine points; several opposed heavy teeth; or a somewhat 
encircling grasp independent of teeth (Fig. 103, No. 6) 

4. Exposing Instruments (Figs. 104 to 108). — Exposing in- 
struments are, as a rule, broad-bladed, blunt hooks, known as 
retractors, of varying sizes that are used to draw back the edges 
of the wound in order to give a better exposure of the deep struc- 
tures. Beyond the limits of this definition come the atypical 
retracting instruments — generally called specula (Figs. 107 and 




Fig. 109.— Surgical needles: (1) Glover's needle ; (2) triangular point; (3) Halsted-Hage- 
dorn; (4) surgeon's half curved; (5) Emmet's half curved; (6,7) intestinal needles; (8) 
surgeon's full curved; (9) Halsted-Hagedorn, full curved; (11) Kelly's; (12) Lister's. 

108). These serve the same purpose, but in a somewhat differ- 
ent way. They are used in order to expand closely approximated 
canals communicating between the outer air and the body 
cavities. Thus, we have nasal, aural, vesical, vaginal and rectal 
specula. They may accomplish their purpose by the simple 
introduction of a tube that gives a free field of vision through 
its lumen (tubular specula), or by the separation of blades that 
force back the adjacent tissues (bivalve or tri valve specula). 

5. Sewing Instruments. — The sewing instruments may be 
divided into needles (Fig. 109) and needle holders (Fig. 110). 
19 



290 THE OPERATIC 

While it is not necessary to use a needle-holder in surface sewing. 
it is quite common for operators who have become used to the 
holder in deep work, where it was necessary, to also use it on the 
surface where this is not the case. The needle-holder is generally 
some modification of an instrument of the clamping type, which 
holds the needle firmly and permits untrammelled work in the 
less accessible localities. The needles used for surgical sewing 
are, if anything, more varied as to construction and application 
than the other surgical accessories, which seem limited only by 
the individual preference of the operators using them. Needles 
may, however, be generally subdivided, according to shape, into 
straight and curved, and, according to section, into round and 
cutting. Tiie use of the straight needle is almost necessarily 
confined to readily accessible parts, as in other regions the re- 
: y of the point after passage might be a matter of considerable 
difficulty. These needles may, in turn, be either round or cutting. 
The round, straight needle does not materially, if at all, differ 
from the ordinary household needle. It is best adapted (as are 
all of the round needles) for work in delicate or friable tissue, 
where the danger of the stitch cutting out is ever present and must 
be reduced to a minimum. It may be said that the generally 
accepted use of the fine, round needle (whether straight or curved) 
is in visceral work where serous surfaces are to be united. This 
includes operations upon the intestines, stomach and urinary 
bladder. Lurge. round needles are also used in work upon the 
liver, kidneys and sometimes the uterus. The cutting needle 
(either straight or curved) does not, necessarily, differ very 
greatly, in appearance, from the round. Its use is primarily in 
tissues here some resistance to the passage of the needle may 
be expected and where the danger from causing hemorrhages or 
of the suture tearing out is slight. The cutting quality is obtained 

the type of point and cross-section. We have. thus, spear- 
pointed needles; the triangular sectioned needle, somewhat like 
an old-style bayonet; and the flattened needle, with a single, 
sharpened cutting edge near the point. The degree of curve of 
a needle may van* from that only slightly departing from the 
straight to that which is almost a perfect semicircumference of a 
small circle. In addition to these may be mentioned the large 
needles and ligature carriers that unite, in one instrument, the 
functions of needle-holder and needle (Fig. 111). 

6. Au\iliar\ Instruments. — The number of instruments sup- 



SURGICAL INSTRUMENTS 



291 




the oferai:::- 




SURGICAL INSTRUMENTS 293 

plementary to, but not definitely identified with, the above 
groups covers a field that cannot be comprehensively covered 
within the limits of a single chapter, or indeed of a single small 
book. We shall, however, make a brief study of a few of the more 
important — those in general and frequent use. For this purpose, 
we shall consider five classes of instruments : searchers, directors, 
dissectors, dilators and evacuators. 

A. The probes are the truest type of searchers (Fig. 112, 
Nos. 1 and 2). They are of varying size to permit of introduction 
in passages of the smallest size and large passages whose known 
dimensions are fairly constant and ordinarily of a fairly soft 
metal to permit of shaping by hand so as to follow the curves 
of the passage. Their function is diagnostic, — the exploration 
of a cavity or passage that is not subject to visual or digital 
examination. 

B. The directors (Fig. 112, Nos. 4 and 5) are a less commonly 
used group, somewhat resembling the searchers in general char- 
acteristics, but supplied with a grooved track along which the 
back of a knife or scissors blade may be passed accurately in a 
given direction, without danger of additional and unintended 
injury to the parts. 

C. The dissectors (Fig. 112, Nos. 6-8) are absolutely or 
moderately blunt-bladed instruments, used in the careful separa- 
tion of tissues in regions where the use of a knife or scissors might 
cause unnecessary or objectionable destruction of tissue. 

D. The dilators (Figs. 113 and 114) are instruments used for 
the purpose of enlarging already existing orifices either as a means 
of treatment or in order to render the subjacent parts more 
readily accessible. They may be graduated in size, so that the 
introduction of successive instruments produces gradual dilata- 
tion; cone-shaped, so that the gradual introduction of the single 
instrument produces the same result; or bladed, so that the 
gradual separation of the blades, under pressure, procures dila- 
tation. Their most common applications for curative purposes 
are to strictures of the oesophagus, urethra and rectum and dila- 
tation of the uterine cervix for dysmenorrhoea. For purposes 
of rendering the parts more accessible, they are most commonly 
employed in dilating the female urethra, the sphincter ani and 
the uterine cervix (in the last case, to permit thorough curettage). 

E. The evacuators (Figs. 115 and 116), as their name would 
suggest, are designed to remove foreign or excessive fluid from 



SURGICAL INSTRUMENTS 295 

body cavities. They vary from the simple aspirating needle 
(Fig. 116, No. 1), used to remove fluid from joints or other locali- 
ties, for diagnostic purposes, to the heavy trocar and cannula 
(Fig. 116, Nos. 2-5) used for evacuating large ovarian cysts, 
before removal, and include the various catheters (Fig. 115). 
The trocar and cannula consists of a tube (the cannula) which is 
supplied with an accurately fitted, pointed, metal core (the tro- 
car), the point of which projects beyond the tube. This is used 
by forcing the point through the cyst wall (or even the abdominal 
wall), removing the trocar and leaving the cannula in place, 
where it acts as a tubular drain. 

The Care of Instruments. — The first requisite of the proper 
care of all metal surgical instruments is that, when not in use, 
they be dry when put away and that they be kept in a dry place. 
After using, the instruments should be boiled to destroy any 
infectious material that may have adhered during operation. 
They are then mechanically cleansed in soap and water, supple- 
mented, when necessary, for the removal of rust or firmly ad- 
herent particles, by sand soap, Dutch cleanser, or some similar 
preparation. After cleaning, they are carefully dried with cloths, 
the locks lubricated with vaseline or some thin oil, and put away 
in a dry instrument case. When instruments are used only at 
infrequent intervals, as may be the case in private offices or with 
special instruments, it is well to apply a light coat of some thin 
oil, after drying. Cutting instruments should not be sterilized 
in a tray with numerous other instruments, as the edges may be 
nicked or dulled by contact. 

Hollow instruments such as trocars and cannulas and hollow 
needles for hypodermic and aspirating syringes need special care 
to prevent plugging of the tube with rust. Absolute alcohol 
should be run through such instruments after thorough cleansing, 
and a wire smeared with oil or vaseline should always be inserted 
in the hollow needles before putting away. Instruments with 
elaborate joints should receive particular attention to see that 
no moisture remains at places not easily accessible. A costly 
instrument may be easily ruined by carelessness in such par- 
ticulars. 



CHAPTER XXII 

THE ASEPTIC TECHNIC 
I. DEFINITIONS 

The word technic means the correct manner of procedure, in 
all of its minutest details, which is erupted in the proper 
carrying out of any piece of work requiring special knowledge 
and skill. It is, in other words, the right way of doing things. 
Every form of creative or manual activity in which man applies 
himself, including even art and literature, has its own technic; 
that is, the right way of doing that particular thing. An error 
in technic is a departure from the recognized procedure with 
the result of a decrease in efficiency, or a failure to attain the 
best possible result in the final product. 

Let us consider, as a homeh T illustration, the preparation of 
food. Every one knows that a slight and to the novice apparently 
insignificant variation in the manner of preparing and cooking 
an article of food may make all the difference between a whole- 
some, appetizing dish and a nauseating mess. In other cases 
the contrast is not so great. One way of cooking will produce a 
dish that is fairly good, while a slightly different way will add 
to it a delicious delicacy of flavor infinitely superior to the other 
product. Again, there may be several ways of preparing a dish 
giving results a little different but about equally good. Finally. 
there will be cases where there is no general agreement, even 
among the most expert, as to which of two or more methods is 
the best. 

The technic of general surgery covers every surgical procedure, 
from the giving of a lwpodermic to the most extensive surgical 
operation, and in this field also we shall find the same differences 
as those indicated in our illustration, but the results of technical 
errors will be vastly more serious. In the first case we shall have, 
instead of a spoiled dish, perhaps prolonged illness or even loss 
of life of a patient who, if things had been done for him in the 
right way, would have had every chance of a speedy recovery. 
In the second case the bad results of the use of the less efficient 
of two methods may not be so obvious, and yet very serious in 
296 



THE ASEPTIC TECHNIC 297 

reality; since in comparing a long series of operations the tech- 
nical error may show its effect in a much higher mortality. Of 
the third case, where several methods are equally good, there 
are many instances in surgery, and there are also not a few under 
the fourth where technical details are still a matter of dispute. 

It is clear, therefore, that the technic of surgery, like that of 
any other art or industry, does not consist of a set of cut-and- 
dried rules to be learned by rote. Its practice requires knowledge 
and understanding of principles and causes and the intelligent 
application of this knowledge to particular cases under widely 
different conditions; nor is it rigid and unchangeable, but rather 
subject to constant improvement as new facts and methods are 
discovered. 

In the technic of surgery there are three quite distinct divi- 
sions. The first is the aseptic technic, which is concerned with 
the methods of preventing infection in wounds. The second 
part of the operative technic relates to the manner of performing 
the operation itself. It concerns the work of the surgeon almost 
exclusively. Practically all that concerns the work of the nurse 
in connection with it is contained in the chapter on operative 
steps. The most important general principles of operative technic 
are sharp knife dissection, avoiding tearing of the tissues, or any 
unnecessary trauma; exposure of the operative field with the 
least possible mutilation of overlying parts; perfect hsemostasis 
at every stage of the operation; avoidance of constriction of large 
masses of tissue in ligating vessels ; suturing so as to restore proper 
anatomical relations; obliteration of dead spaces; avoidance of 
undue tension in closure. Every separate operation has its own 
technic, the result of constant study and trial to find the most 
efficient way. The path of surgery is strewn with discarded bits 
of operative technic, many of them the result of much ingenuity 
and labor, which have, however, been found wanting in some 
important particular. A full discussion of the subject would con- 
stitute a treatise on operative surgery. The third division of the 
surgical technic concerns the management of the individual 
patient before, during and after an operation; how he can be 
brought to the best possible condition, both physical and mental, 
to meet the ordeal that is before him; how he can be carried 
through that ordeal with the least risk, the minimum amount of 
suffering, the smallest drain upon his vital forces, and how he can 
be brought to full restoration of health in the shortest possible time. 



298 THE OPERATION 

By the term " sterilization " we mean the absolute destruction 
of all single-celled organisms. An object or a material is sterile 
when it contains no living organisms, either upon its surface or 
within its substance. " Disinfection " is an older term with a 
somewhat less precise meaning. It is used rather loosely to 
indicate either the destruction or rendering inert and incapable 
of harm any of the infectious or pathogenic organisms. The 
word " antiseptic " is used in a somewhat similar way. its mean- 
ing, however, being restricted to the effect upon the bacteria 
concerned in septic infection. 

Thus since we know that we cannot sterilize the hands or 
the skin of the patient in the region to be operated upon, we 
speak of disinfecting them when we use the best means we have 
for rendering them as free as possible from living organisms. 
When we apply a chemical solution, such as bichloride of mercury, 
to a wound, with the purpose of cleansing it. we call it an anti- 
septic solution. Such solutions do not accomplish the purpose 
intended very efficiently, for several reasons. In the first place, 
we know of no chemical which will kill bacteria that is not also 
destructive to the tissue cells. Moreover, the bacteria are not 
all on the surface, but embedded in the tissues, so that the 
solution does not reach them. Finally, we have to contend with 
the fact that solutions which will readily kill bacteria in the 
laboratory will often be rendered more or less inert when in 
contact with organic material. " Aseptic " means freedom from 
septic bacteria. Thus we say a wound is aseptic when it contains 
no septic organisms. 

When, by some injurious effect brought to bear upon 
them, bacteria are not killed but are rendered inert or inactive, 
so that they cannot grow or multiply, at least for a time, 
we say that the}' are " inhibited." The effect of our disinfec- 
tant and antiseptic solutions, particularly in the more 
dilute preparations, is often to inhibit bacteria rather than to 
kill them. 

The thermal death point for bacteria is the temperature at 
which they are killed, in the presence of abundant moisture, 
after an exposure of ten minutes. For many of the pathogenic 
bacteria this temperature is not very high: 60° C, or 140° F , 
is the thermal death point for the typhoid bacillus. 65° to 70° C. 
for the tubercle bacillus, and a somewhat higher temperature 
for the pyogenic bacteria. 



THE ASEPTIC TECHNIC 299 

II. THE FIRST PRINCIPLES OF ASEPSIS 

1. Given proper coaptation, or fitting together, of wounded 
tissues, and rest {i.e., prevention of motion in the wounded part), 
almost the sole remaining obstacle to prompt wound healing lies in 
the invasion of the wound by one of about half a dozen species 
of bacteria known as the septic or pyogenic group. When these 
are absent wounds heal normally; when they are present septic 
disease results in the wound, delaying healing or preventing it 
altogether. 

2. All men and all the higher animals, probably, are chronic 
carriers of this group of bacteria, and everything handled by 
man is quite certain to be contaminated with them. 

3. The constant dwelling place of these germs is upon the 
skin and mucous surfaces of the body, the tissues of the interior 
of the body being normally free from them. 

4. Although it is possible for wounds to be infected in several 
ways, for example through the air, or through the blood stream 
(since bacteria occasionally find their way into the blood and 
may survive there for short periods), yet practical experience 
shows that almost the sole cause of wound infection is the con- 
veyance of bacteria by contact, or by direct implantation into 
the wound of some germ-bearing material. 

5. Prevention of infection in wounds, therefore, requires that 
everything that comes in contact with a wounded surface must 
first be rendered sterile, i.e., entirely free from living, single- 

t celled organisms. 

6. The most efficient means of sterilization is heat, and this 
should be the method employed wherever possible. In order 
to sterilize any article it must be subjected to dry heat at 150° C. 
(302° F.) for one hour, or to steam at ordinary pressure for one 
hour, or to steam at fifteen pounds pressure for thirty minutes, 
or to boiling water for ten minutes. These represent the minimum 
requirements in practical work. 

7. Any object that has been sterilized which afterwards 
comes into even momentary contact with an unsterilized object 
thereby ceases to be sterile. 

8. The sterilization of the skin is the most difficult problem 
in the aseptic technic, because the application of heat as a steril- 
izing agent is impracticable and because bacteria are contained 
in the crypts of the skin glands and follicles, where disinfecting 
solutions cannot readily reach them. 



300 THE OPERATION 

III. STERILIZATION BY HEAT 

The only reliable method b}^ which objects or material can 
be sterilized within a short time, measured in minutes, is by the 
application of heat in some form. Dry heat means heating in 
the air, as in an oven. Moist heat may be emploj^ed in the form 
of water or of steam. Steam may be employed either as free 
flowing steam or confined under pressure in a closed air-tight 
chamber. 

The factors which must be taken into account in sterilizing 
by heat are, (1) the susceptibility of the organisms to be killed, 
(2) the degree of temperature to be employed, (3) the time of 
exposure, (4) the presence of moisture, and (5) the liability of the 
articles to be sterilized to be themselves affected by heat. Bac- 
teria in the active or " vegetative " stage are, as has been said, 
killed at a comparatively low temperature; but bacteria in the 
resting stage, i.e., the spore-forming bacteria, resist the tempera- 
ture of boiling water or free steam for more than an hour. In 
sterilizing culture media in the laboratory a method known as 
" fractional " or " discontinuous " sterilization is used in order 
to make sure of the destruction of the spore-forming organisms. 
This consists in repeating the sterilizing process for three days 
in succession, the object being to allow the spores which may be 
present to grow out into the vegetative form during the intervals 
between the successive sterilizations, they being then readily 
killed when heat is next applied. This method applies only to 
liquids or moist materials, since spores will not grow out when dry. 

The higher the temperature the less the time of exposure 
needed. The temperature of the flame kills bacteria instantly, 
but most objects to be sterilized would themselves be destroyed 
by such high temperatures. We have to determine the time of 
exposure therefore in accordance with the degree of heat that 
can be safely used. Dry heat will scorch or injure most materials 
at a higher temperature than from 150° to 180° C. (365° F.). An 
exposure of an hour to dry heat at this temperature is necessary 
to destroy spore-forming bacteria. Dry heat does not penetrate 
easily into packages of woven goods. 

Moist heat is more efficient than dry heat as a sterilizing 
agent, i.e., at the same temperature. Thus moist heat at 100° C. 
(212° F.), which is the highest temperature we can obtain from 
boiling water, or free steam, is about equal in sterilizing power, 
with the same time of exposure to dry heat at 150° C. 



THE ASEPTIC TECHNIC 301 

To obtain the most efficient sterilization by means of heat 
we must employ moist heat, in the form of steam, at a higher 
temperature than 100° C, and to do this it is necessary to apply 
the steam under pressure in an air-tight and steam-tight chamber. 
The apparatus employed for this purpose is known as a pressure 
sterilizer or autoclave. 

The temperature at which water boils, and therefore the 
temperature of the steam given off, depends on the pressure upon 
the water surface. In the open air this pressure is due to the 
weight of the atmosphere, as is shown by the fact that water 
boils at a lower temperature at high altitudes than at the sea 
level. When water boils in a closed chamber the steam given 
off itself rapidly increases the pressure on the surface of the water. 
When the pressure at a given temperature becomes just sufficient 
to check the further giving off of vapor from the surface, the 
space above the water is said to be saturated with steam. Now 
if the water is further heated more vapor will be given off, and 
the pressure will be increased. The atmospheric pressure at 
sea level is about 15 pounds to the square inch; if we add another 
18 pounds of pressure, the temperature of the saturated steam 
in the autoclave will be about 275° F., or 135° C. Moist heat at 
this temperature will kill all bacteria, including spores, after an 
exposure of twenty minutes. This is about the temperature used 
in the operating room for the sterilization of dressings and other 
materials. So long as the steam is in contact with the surface 
of the water the closed space will be filled with saturated steam, 
whatever the temperature may be. But if the steam is cut off 
from the surface of the water, or the water is all boiled away, 
and if then the steam is still further heated, its condition changes, 
it becomes " dry " steam and its sterilizing power will then be 
only equal to that of dry air at the same temperature. 

IV. OUTLINES OF THE ASEPTIC TECHNIC 

1. Methods of Sterilization. — The various methods in prac- 
tical use and the manner of using them have already been de- 
scribed. It is sufficient here to present a summary of their appli- 
cation to the sterilization of the different materials employed in 
operative work. 

(1) Articles to be Sterilized by Steam. — Covers for the operating 
and instrument tables (rubber sheets and cotton sheets); sheets 
and towels to drape and cover the patient's body, except the 



302 THE OPERATION 

field of operation; gowns, masks, and caps for the operator and 
assistants; sponges, packs, silk and linen sutures, and ligatures; 
gauze for dressings; flasks of saline solution, olive oil for lubri- 
cating catheters, camphorated oil for hypodermic use, vaseline, 
zinc ointment, etc. 

(2) Articles to be Sterilized by Boiling in Water, or One Per 
Cent. Solution of Carbonate of Soda (Washing Soda). — All metal 
instruments (except the cystoscope); rubber gloves; sealed glass 
tubes containing catgut and kangaroo tendon sutures and liga- 
tures furnished by the manufacturers; glass and soft-rubber 
catheters and drainage tubes; basins and irrigators. 

(3) Articles to be Sterilized by Dry Heat. — Glassware; catgut 
(in preparation). 

(4) Articles to be Sterilized by Chemical Solutions. — Gutta- 
percha tissue (in 1 to 1000 bichloride of mercury solution) ; skin 
of the patient in the field of operation (iodine and alcohol, or 
bichloride solution) ; hands of the operator and assistants (alcohol, 
bichloride solution, permanganate of potash and oxalic acid 
solutions, etc.); gum catheters (bichloride); Kelly pads (1-20 
carbolic). 

(5) Articles to be Sterilized by Formalin Vapor. — Cystoscopes; 
gum catheters; and perhaps a few other special instruments. 

2. Assembling and Handling the Sterilized Outfit. — The 
various articles required for an operation, sponges, packs, dress- 
ings, towels, sheets, etc., are put up in individual packages 
before they are sterilized, and the total requirements for a single 
operation (i.e., all those that are to be sterilized by steam) are 
assembled in one or two large packages or drums. In these 
they are carefully arranged in due order, those that are to be 
used first on top and those that will be needed later at the bottom, 
so that there need be no pulling about of the various articles to 
get what is wanted at any time. First, towels and sheets for 
covering instrument and dressing table; next, nurses' and opera- 
tors' gowns, caps and masks, covers for the operating table, 
operating sheet with hemmed opening in centre; lastly, towels 
for surrounding the field of operation. Articles which are to 
come into contact with the wound itself, sponges, packs, and 
dressings, may be in a separate drum or package. All sponges 
and packs should be counted twice, preferably by two nurses 
separately, at the time they are put up, all packages containing 
the same number. The time for sterilization of this outfit should 



THE ASEPTIC TECHNIC 303 

be arranged so that it will be ready shortly before the operation. 
In the steam sterilizer the packages or drums should be subjected 
to ten minutes' vacuum, thirty minutes' steam, followed by ten 
minutes' vacuum. Instruments and all articles that are sterilized 
in boiling water are arranged in a tray in the instrument sterilizer, 
boiled ten minutes, and brought direct to the instrument table 
in the tray, from which they are taken by the nurse and placed 
on the table in proper order. 

The operating force is divided into two groups: the clean 
group, consisting of the operating surgeon, two assistants, and 
one or two nurses; and the not-sterile group, consisting of the 
anaesthetist, one or two nurses, and an orderly. Each member 
of the clean group, after being cleaned up, gowned and gloved, 
must see to it that no part of his clothing comes in contact with 
any article that has not been sterilized, particular care being 
taken that the hands touch nothing not surgically clean. The 
first lesson to be learned is that the face is never surgically clean. 
All handling of unsterile articles is done by the not-sterile group, 
all handling of sterile articles by the clean group. Thus, packages 
are opened by the unscrubbed nurse, their contents are removed 
by the clean nurse. 

3. Preparation of Members of the Clean Group. — Two points 
are to be considered here: (1) the cleansing and disinfection of 
the hands, and (2) the manner of putting on the sterilized gowns, 
gloves, masks and caps. The methods in use for hand disinfec- 
tion vary according to individual ideas. All the methods include 
the two steps of thorough scrubbing with soap and water for ten 
minutes, followed by immersion in some antiseptic solution for 
five minutes or more, for example, in 70 per cent, alcohol (one 
minute) and 1-1000 bichloride (five minutes). One point already 
referred to needs particular emphasis. There is a great deal of 
difference in the susceptibility of the skin of different individuals 
to the irritating effects of antiseptic solutions. When any such 
solution makes the skin of the hands rough it is an error in technic 
for that individual to continue the use of that solution. The 
same is true of the use of the scrubbing brush. A piece of gauze 
is equally efficient for hand cleansing, and should be used instead 
of the brush whenever the latter is a source of irritation. Super- 
latively clean hands are a necessity, but an irritated skin is a 
greater source of danger than the failure to use strong antiseptics. 
Alcohol at least can always be used. 



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THE ASEPTIC TECHNIC 305 

have no holes in them when they come from the sterilizer. This 
can only be done by lifting them with sterile forceps while filled 
with water, so that any leak will show itself. After the gloves 
are on the gown is picked up and held at arm's length while it 
is unfolded and the hands slipped into the armholes; the arms 
are then held straight in front while the unscrubbed nurse pulls 
the gown into place by means of the tapes, which are then tied 
at the back. The cuffs of the gloves are then pulled over the 
sleeves. The unscrubbed nurse also adjusts the sterile cap and 
mask for each member of the clean group, who must not use their 
own hands for this purpose. The toilet of the patient, who may 
be considered a member of the clean group, consists of two steps : 
disinfection of the skin in the field of operation and covering 
all the rest of the body except the face with sterile sheets and 
towels. Tincture of iodine diluted with alcohol is now almost 
universally used for skin disinfection in the field of operation. 
The first thing to be remembered is that the skin should be 
absolutely dry. Scrubbing with soap and water should be done 
on the previous day, as should also the shaving. If it is necessary 
to shave immediately before the operation this should be done 
dry with the use of benzene. The skin should also be free from 
grease, and to this end a preliminary washing with some oil 
solvent (ether, turpentine, benzene) may be employed. The 
method employed at the Mayo clinic, copied from that in use 
at the clinic of Dr. Bastianelli in Rome, consists of applying two 
solutions to the skin. The skin is first lightly rubbed with a 
solution consisting of one part of iodine crystals to 1000 parts 
of benzene. Tincture of iodine, diluted one-half with alcohol, 
is then painted over the skin. One coat is enough. A wide area 
about the proposed wound should be covered. Blisters may 
result in skin creases if the solution is allowed to run into them 
and dry slowly. Bichloride or other antiseptic watery solution 
should never be employed to supplement the iodine disinfection, 
for blistering is sure to follow if this is done. At the close of the 
operation the iodine is washed off with alcohol to which a few 
drops of an alkali (soda, potassa, ammonia) have been added. To 
drape the patient, towels are first arranged about the field of 
operation; the operating sheet with its hemmed opening then 
covers the entire body of the patient except his head; finally, 
four towels are arranged about the opening in the sheet. 

4. Conduct During the Operation. — It goes without saying 
20 



306 THE OPERATION 

that the same care must be continued to avoid contact with 
unsterile articles, particularly by the hands. If aecid- 
contact with the hands occurs the gloves should be changed. 
This should also be done if a glove is perforated by a knife or 
needle during the course of the operation. Instruments that 
touch anything not sterile should be instantly discarded and 
resterilized by boiling before being used again. When any hollow 
viscus (stomach, intestines, appendix, gall-bladder, urinary 
bladder, ureter, pelvis of the kidney) has been opened in the 
course of an operation, all instruments that have been used within 
the cavity of the viscus and the needles and sutures employed in 
its closure are contaminated and should never be replaced among 
the other clean instruments, or handed back to the surgeon for 
use in a later stage of the operation, for instance in closure of 
the wound. Such instruments should be discarded as soon as 
the surgeon has finished using them, and the instrument nurse 
should avoid touching them with her gloved hands. Towels 
about the wound should be changed when they are soiled or, in 
any case, before the wound is sutured. Strict count must l>e kept 
of packs and sponges so that none may be left in the wound. 

5. Conduct Between Operations. — Every operation is a thing 
by itself. A complete new outfit is required for each operation, 
no part of the preparation for a previous operation being carried 
over for the next. The long hand scrubbing need be done only 
once on each operating day, its repeated performance being too 
severe upon the skin, but fresh sterile gloves must be put on 
for each operation. Care of the operating room has been de- 
scribed elsewhere. Its chief requirement is strict cleanliness, 
without too much reliance upon the antiseptic solutions used to 
wipe the articles of furniture. Accumulations of dust in forgotten 
places to be blown about in the air must not be permitted. Open- 
air ventilation is desirable, but all windows should be screened. 
Flies and other insects must be absolutely excluded. For all 
who take part in the work of the surgical operating room the 
obligation of habitual personal cleanliness arises from reasons 
more imperative than the standards of good breeding. Particular 
care should be taken of the hands. The nails should be attended 
to and should neither be allowed to grow too long nor be cut too 
short. Suppurating wounds or the dressings from them should 
never be handled without gloves. The mouth and, particularly, 
the teeth should receive scrupulous attention. Neglect of the 



THE ASEPTIC TECHNIC 307 

dentist is a serious error in the aseptic technic. After being used 
in an operation all instruments and basins must be resterilized 
by boiling in water before being put away, or before they are 
used in another operation. 

V. THE SUPER-TECHNIC 

The aseptic technic presented in the foregoing outline repre- 
sents in substance that which is now in use in the majority of 
operating rooms. There are, of course, some variations in minor 
details. Considered from the theoretical standpoint this technic 
falls very far short of the standards of perfection. Experience 
shows, however, that it is sufficient to insure the absence of 
septic infection in the great majority of clean operative wounds. 
A perfect technic is probably impossible at the present time, and 
it may be here pointed out that super-refinements in minor de- 
tails, applied haphazard here and there, do not as a rule bring 
us measurably nearer that goal. There are, however, some classes 
of operations where the tissues involved are peculiarly liable to 
infection, and where, moreover, infection is particularly disastrous. 
The principal operations of this group are those that involve the 
opening of the larger joints, the transplanting of tendons, and 
the so-called open operations for fractures. In these cases 
experience seems to justify certain additional precautions and 
the adoption for these particular cases of what may be called 
a super-technic. 

Instruments, sponges, sutures and ligatures are given a 
double sterilization time. Silk or linen sutures, sometimes used 
for artificial extension of tendons in transplanting, are boiled 
for an hour in bichloride solution. The knife used for the 
primary skin incision is laid aside and a new knife used for the 
deep dissection. As soon as the skin is incised particular care is 
taken in fastening towels by means of clamps to the subcutaneous 
tissue so as to cover all the skin and its cut edges. Only instru- 
ments and sponges are allowed to enter the wound, the gloved 
hands being kept altogether out of it. The gloves do not touch 
that part of an instrument which enters the wound. The instru- 
ment nurse, therefore, must pick up instruments only by the 
handles, and in handling ligatures and sutures she must use 
instruments altogether, not touching them with her gloved hands. 
In threading a needle she picks up the needle with one clamp 
and the thread with another. The surgeon will use extreme care 



308 THE OPERATION 

so as to avoid constriction of tissue, will never use a drain, and 
in closing the wound will avoid tension as much as possible. 

VI. BREAKS IN THE ASEPTIC TECHNIC 

We have emphasized the importance of a rigid adherence 
to the aseptic technic in every smallest detail. The strength of 
this obligation, in fact, cannot be overstated. And yet, as we 
have pointed out, there are (from a theoretical standpoint) a 
number of weak places in the aseptic precautions as now prac- 
tised. We ignore infection from the air. We cannot sterilize 
the skin. Septic bacteria may be, and probably sometimes are, 
carried to the wounded tissue through the blood stream. It is 
true, also, that wounds frequently heal without suppuration in 
spite of rather glaring departures from the accepted standards 
of aseptic practice. These facts seem to furnish a reasonable 
excuse for a certain amount of carelessness and indifference. 
Since wounds may suppurate in spite of all precautions, and 
since some do not suppurate when precautions are neglected, 
what is the necessity for all this trouble? The most convincing 
answer to this question lies in an appeal to the teachings of 
experience. The aseptic technic as we have it is the result of a 
vast amount of scientific and practical study extending over a 
period of many years. The most striking result has been the 
demonstration of the immense preponderance of the danger of 
infection by contact or implantation over all other forms. Experi- 
ence proves conclusively that the means we have, if properly 
carried out, are adequate to prevent infection in practically all 
clean operative wounds. Suppuration in a wound from unavoid- 
able causes is so rare that in no single instance have we the right 
to assume that the infection was not due to a technical error. 
Whenever in a hospital a series of infected wounds occurs we 
may be certain that there is somewhere a broken link in the 
chain of precautions against contact infection which will reveal 
itself to a sufficiently rigid investigation. Obviously, then, the 
utmost vigilance should be exercised, at all times, to forestall 
any such unfortunate occurrence. 

It is impossible to enumerate all the possible breaks in the 
technic. It is needless to repeat such old stock illustrations as 
that of a nurse picking up an instrument from the floor or of a 
surgeon holding an instrument in his teeth. Such gross breaks 
do not occur any longer if indeed they ever did. The technical 



THE ASEPTIC TECHNIC 309 

errors which still occasionally appear are far more subtle and 
complex in character. It will be best, perhaps, to illustrate the 
subject with a few actual instances. It should be said at the 
outset that these happened in different hospitals and in different 
cities, the actual place, in the cases selected, being unknown to 
the writers themselves. It is probable that the same things have 
happened in a number of institutions. The instances are true 
in substance, although as they are related from memory accuracy 
in details is not vouched for. 

In a large hospital, during a period of one month, there 
occurred some twenty cases of infection in wounds. The majority 
were insignificant stitch abscesses; in other cases the entire 
wound broke down and suppurated freely; there were a few 
cases of severe sepsis; one died. On investigation it was found 
that a new force of nurses had been assigned to the operating 
room at the beginning of the month. These inexperienced nurses 
had been put in charge of the autoclave without sufficient instruc- 
tion in its use. After placing the goods in the chamber and closing 
the door, the vacuum valves had not been opened to remove the 
air from the chamber before turning in the steam. As a result 
none of the sponges, packs or dressings used during this period 
had been properly sterilized. 

In another hospital a large number of stitch abscesses oc- 
curred; a few of the infections were rather severe, but, fortunately, 
there were no fatalities. Bacteriological examinations showed 
that in every instance the colon bacillus was one of the organisms 
present. The colon bacillus, it will be remembered, is a normal 
inhabitant of the intestinal canal. An investigation disclosed 
the fact that in some of the wards of the hospital the preparation 
of the patients for operation had been done in a hasty and careless 
manner. The giving of the enema was frequently postponed 
till the last minute, many of the patients going to the operating 
room before a satisfactory result had been obtained. As a result 
soiling of the operating table with liquefied fecal matter was a 
rather common occurrence. The orderly who carefully cleaned 
up afterwards, using the customary antiseptic solutions, was 
observed to wipe the instrument tables with the same cloth. 

A surgeon, having observed a few unexpected infections 
following some of his operations, suspected that something was 
amiss in the technic in his operating room. He could find nothing 
wrong, so he asked a competent friend to see what he could 



310 THE )PERAHON 

discover. The friend arrived in the operating room an hour 
before the operation and. watched, the preparation. He could 

find, nothing to criticise except in one particular. The Bstnt- 
ment nurse was the unfortunate possessor of a very delicate 
skin. Her hands were rough and sore as a result :: the rigorous 
hand disinfection which was insisted, upon. This condition ~ii 
aggravated by prolonged, wearing of the rubber gloves which were 
required, to be put on while filled with bichloride solution. In 
order to save her hands as much as aied the packs 

and c - - - and distributed the instruments with : - jyids, 
putting on the gloves at the last moment before the operation. 
[t is probable that such a break as this would not hare I 

results sufficient to arouse the suspicion of the surgeon, except 
:':: :he inflamed condition of her hands, which encouraged the 
growth of septic bacteria upon them in spite of the Esnfectng 
solutions which were employe - 

The few random instances here cited show how widespread 
may be the origin of breaks in the aseptic technic. The fault 
in one ca :ed to insufficient preparation in the ward and 

a later careless technic by the operating orderly. Another s - 
of infections was due to the sterilization of dressings by insuffi- 
ciently instructed nurses. A third series found its origin in the 
hands of the instrument nurse herself. Other cases might easily 
be given where the fault lay with the surgeon alone, or when it 
was traceable ' ~~- -kness in other links in the aseptic chain. 
With such results before us in the form of conere - - ins* i rs 

;lear that there is little present danger -:efineme: 

over-emphasis of this, the most importar." -.__ .: .---.. :ment 
of modern surger 



CHAPTER XXIII 

PREPARATION FOR AN OPERATION AND THE 
OPERATING-ROOM PERSONNEL 

I. PREPARATION OF THE OPERATING ROOM 

1 . Necessary Equipment. — In considering the question of the 
necessary equipment along any line, the subject should be intro- 
duced with the caution that lists of implements or materials 
should not be systematically memorized, as this process is not 
only an unnecessary strain upon the memory, but is almost 
sure to lead to the forgetting of something. The question should 
always be approached with a definite understanding of the 
requirements of the occasion and then treated logically and by a 
process of systematized reasoning. Such will be our endeavor 
in this and subsequent similar descriptions, in order to demon- 
strate the greater ease and reliability of this method over the 
memory-taxing one. 

A. For the Patient. — An operating table. A tray with the 
necessary articles for preparing the field of operation and for 
catheterizing. The necessary sterile towels and covers. 

B. For the Anaesthetist. — A stool upon which to sit while 
giving the anaesthetic. A stand holding the necessary anaesthetic 
supplies, towels, hypodermic outfit, etc. A stand prepared for 
the subcutaneous administration of salt solution. 

The stand for the] anaesthetist should contain: (1) ether mask, 
freshly covered; (2) mouth gag; (3) tongue forceps (Fig. 102, 
No. 4); (4) two cans of ether, sealed; (5) three large safety-pins; 
(6) six small towels; (7) a piece of gutta-percha tissue, 3 by 5 
inches; (8) sterile vaseline to protect the skin from ether; (9) a 
one-ounce bottle of sterile olive oil or castor oil for use in the 
eyes when irritated by ether; (10) three or four curved clamps, 
such as the Kelly-Pean (Fig. 129, No. 8); (11) ten or more folded 
strips of gauze, 2 by 6 inches, for clearing mouth and throat 
from mucus. 

In addition there will be provided for the anaesthetist a hypo- 
dermic tray containing two hypodermic syringes, sterile, with 
the following preparations and drugs, in suitable doses, preferably 

311 



312 THE OPERATION. 

contained in sterile ampoules ready for instant use: strychnia, 
atropine, caffeine, nitroglycerin, adrenalin, digitalin, morphine, 
camphor in oil, camphor in ether. 

For the administration of nitrous-oxide-oxygen ansesthesia 
special forms of apparatus are required, of which there are many 
styles on the market. If the operating room is not provided 
with one of these, a large iron flask of compressed oxygen gas 
should be at hand for use if required. 

The outfit for subcutaneous infusion of saline solution should 
include: iodine-alcohol preparation (equal parts) for skin steril- 
ization; a two-litre flask of sterile normal saline solution, warmed 
to 120° F. ; an irrigation stand (Fig. 89) with sterile glass graduated 
container, covered with sterile towel; three sterile infusion needles, 
with sufficient length of sterile rubber tubing to make connections. 

C. For the Operator and Assistants. — For each a separate 
wash stand with foot pedals for the control of the running water. 
Upon each stand should be a tray containing a sterile scrub 
brush, an orange stick (or nail file) and another tray containing 
green soap. A stand with three basins containing, respectively, 
alcohol (50-95 per cent.), bichloride of mercury solution (1-1000) 
and sterile water. Basin of bichloride solution with rubber 
gloves. Gowns. If the operation is vaginal or perineal, there 
should also be a stool for the operator. 

D. For the Scrubbed Nurses. — The same supplies for scrubbing 
as for the doctors, but in another room. Also gloves and gowns. 
A table upon which the instruments and suture materials are 
to be arranged. A table upon which the sponges, packers, towels, 
covers, dressings, etc., are to be arranged. A stand with two 
basins containing, respectively, a solution of bichloride of mercury 
(1-1000) and a solution of salt (0.9 per cent.). 

E. For the Unscrubbed Nurse. — One basin upon the floor on 
either side of the operating table for used sponges, for the count 
of which she is responsible. 

Lastly, the sterilized instruments for the operation are brought 
in and put upon the instrument table already mentioned. 

The equipment of the room having been enumerated, we 
can now summarize and particularize as to the necessary prepara- 
tion of the different articles. As a general statement, we may 
say that everything in the operating room should be kept mechan- 
ically clean. In addition to this, everything that will stand 
boiling should receive it before each operation. In the case of 



PREPARATION FOR AN OPERATION 313 

tables and other large articles that cannot very well be put in a 
sterilizer, after mechanical cleansing with soap and water, they 
should be thoroughly gone over with a solution of bichloride 
(1-1000) or carbolic (1-20). The walls should be frequently 
gone over with damp cloths to prevent the accumulation of dust, 
and at regular intervals with cloths wet in an antiseptic solution. 
The floor should be kept scrubbed down with soap and water 
and gone over with an antiseptic solution. At regular intervals 
the room should be sealed and fumigated with formalin vapor. 
Non-absorbable sutures and the instruments are sterilized by 
actual boiling for at least ten minutes, as are the gloves. Absorb- 
able suture material is generally put up in sterile containers,, 
frequently in an antiseptic solution, after careful sterilization 
by heat, chemicals or a combination of both. Dressings, towels, 
sponges, packers, covers and gowns are sterilized by exposure 
to live steam under pressure in an autoclave. 

II. PREPARATION OF THE NURSE 

1. Cap. — As the primary purpose of all preparation on the 
parts of operator, assistants, and nurses is the prevention of the 
introduction of extraneous infectious material into the wound 
or field of operation, the procedure naturally divides itself into 
two steps: the sterilization, so far as possible, of those parts 
brought into closest contact with the patient, and the covering 
of what is not sterile with sterilized material. As the falling 
of hair or dandruff into the wound, on the instruments, dressings, 
or on the field of operation would be a source of constant danger, 
caps (either sterile or freshly washed) are supplied, which have 
a draw-string that brings them in snugly to the head, closely 
covering the hair. This cap is generally applied before scrubbing. 

2. Scrub. — The materials for the nurse's scrub are the same 
as those already enumerated for the doctor's. The nails (which 
should be kept trimmed short) are carefully cleaned with the 
orange stick, both beneath and around the borders. The hands 
and forearms are thoroughly scrubbed with the brush and green 
soap (both sterile) and water for five minutes by the clock. The 
hands and forearms are then thoroughly gone over with alcohol 
and then the bichloride solution. 

3. Gown and Gloves. — The sterile gown is then put on, 
some one who is not scrubbed fastening it in the rear. Finally, 
the sterile gloves are put on, the sleeves of the gown being tucked 



314 THE OPERATION 

into the wrist piece of the gloves. It should be fully appreciated 
that the wearing of gloves does not in the slightest excuse the 
neglecting of full attention to the scrub. Should the gloves by 
any chance be torn or pierced by a needle during the course of 
the operation, unclean hands would be just as serious a jeopardy 
to the patient as though gloves had never been worn. The 
scrubbing should therefore be quite as conscientious with the 
use of gloves as without them. 

III. OPERATING-ROOM PERSONNEL 

Having considered the equipment and preparation of the 
operating room for use, as well as the methods of preparation 
adopted by the different individuals, it is advisable that we should 
review the personnel of the operating-room staff and the duties 
pertaining to each of its members. In covering this field, we 
shall endeavor to adhere to a logical order of discussion, as has 
been our effort in the preceding pages. The order of discussion 
chosen will be based upon the relation of each individual to the 
patient, rather than to the operating room or to the hospital. 
The patient and table being so placed that the field of operation 
receives the best possible light, the first duties in regard to the 
patient are assumed by the anaesthetist. 

1. Anaesthetist. — The importance of the duties and the respon- 
sibility of this member of the operating staff are becoming so 
widely recognized in all well-conducted hospitals that it seems 
scarcely necessary to emphasize them in this place. There does, 
however, exist among some people an unfortunate attitude 
toward this important position that would tend towards its 
belittling. The two individuals immediately responsible for the 
life and welfare of the patient are the surgeon and the anaesthetist, 
and the responsibility is equally divided. Let those who would 
question this conclusion take the question home and ask them- 
selves how much care they would take in selecting their anaes- 
thetist as well as their surgeon. The answer is foregone. The 
anaesthetist should be a specialist in his particular line as well 
as the surgeon. Wide experience, sound judgment and invariable 
coolness and decision are as much the requirements of the one 
as of the other. The anaesthetist should have the deciding word 
as to the choice of the anaesthetics, — his special knowledge along 
these lines particularly fitting him to judge which would best 
serve the interests of the patient. He administers the chosen 



PREPARATION FOR AN OPERATION 315 

anaesthetic and it is for him to say when anaesthesia is sufficiently 
deep for the operation to begin; what the condition of the patient 
is at the various stages of the operation; when, if at all, the 
administration of stimulants becomes indicated; and when the 
condition of the patient indicates the advisability of hastening 
the termination of operative measures. If stimulants or restora- 
tives are indicated, it is within the province of the anaesthetist 
to decide upon the medicament and the method of administra- 
tion, and even to undertake the administration. And, in con- 
clusion, it may be of interest to note that this field of operative 
work is one into which the graduate nurse is taking an increasingly 
important part, the anaesthetic work in some of our most impor- 
tant clinics being in the hands of nurses. 

2. As regards the duties of the operator, little need be said, 
the term and its attendant duties and responsibilities being well 
recognized and self-explanatory. In abdominal operations, he 
generally stands at the right of the patient. 

3. The first assistant stands upon the opposite side of the 
table from and facing the operator, in abdominal work, and at 
his right side in vaginal, perineal, or rectal operations. 

4. The second assistant stands on the same side of the table 
with and at the right side of the operator, in abdominal work, 
standing at his left in minor operations. 

5. The nurse in charge of the instruments stands between 
the first assistant and the instrument table, in abdominal opera- 
tions, and between the operating and instrument tables in minor 
operations. 

6. The nurse in charge of sponges, dressings, etc., stands 
between the operating table and the dressing table, at the left 
of the first assistant and opposite the second assistant (Fig. 117). 

7. The unscrubbed (" dirty ") nurse has no particular 
station, but does not leave the operating room except by the 
direction of the operator or one of the assistants. 

8. The orderly should be without the operating room but 
within easy call, so that there will be no delay in his attendance 
if needed. 

This brief summary of the personnel of a properly equipped 
gynaecological operating room places seven persons on continuous 
duty throughout the course of each operation, and should, as a 
result, impress upon each individual how great must be the care 
of each and every one of those concerned to prevent the slipping 



316 



THE OPERATION 



in of those little errors of technic that, possibly of little apparent 
significance, so jeopardize the success of the operation and the 
welfare of the patient. It is scarcely necessary to point out 
that the probabilities of such slips must increase directly with 
the number of personal links in the aseptic chain, and this un- 





^CElDo] 3 Q © 




DD 



16 



15 



Fig. 117. — Diagram of arrangement of operating room. 1 . Operating table. 2. Instru- 
ment and dressing table. 3. Solution stand for surgeon. 4. Solution stand for nurse. 
5. Stool for anaesthetist. 6. Table for anaesthetist. 7. Irrigation stand. 8. Solution 
stand for hand preparation. 9. Table for basin of gloves. 10. Surgeon. 11. First assist- 
ant. 12. Second assistant. 13. Instrument nurse. 14. Sponge and dressing nurse. 15. 
Door leading into main hall of operating suite. 16. Door leading into doctors' scrub 
room or dressing room. 

avoidable increase in the staff should be accompanied by an 
equal effort to avoid the slightest possibility of error. 

IV. DUTIES OF OPERATING-ROOM NURSES 

In our discussion of the operating-room personnel, we included 
three nurses as necessary for the proper conducting of the work. 
These should be, in order of seniority, the unscrubbed nurse, the 
nurse in charge of instruments and sutures and the nurse in charge 
of dressings, sponges, etc. In those smaller hospitals with but 
one operating room, the graduate nurse in charge of the operating 
room should fill the duties of unscrubbed nurse. In the larger 
hospitals with an operating suite consisting of several rooms, the 



PREPARATION FOR AN OPERATION 317 

ideal arrangement would be to have a graduate in charge of 
each room; but, should this be impossible, the term of service 
in the operating room should be for at least three months, the 
first month at the sponge table, the second at the instrument 
table and the third as unscrubbed nurse. As the duties of this 
position are developed, the reasons for the emphasis placed upon 
it will become apparent. 

1. Unscrubbed Nurse. — The unscrubbed nurse is responsible 
for the final preparation of the patient upon the table. She 
catheterizes the patient and gives the final scrub, or applies the 
iodine solution where the iodine preparation is used. She makes 
sure that the solution basins for the surgeon and for the nurse 
are filled with the proper solutions; that the instrument nurse 
has all the necessary instruments and sutures; and that the sponge 
and dressing nurse has the proper supplies for the operation. In 
addition to these duties is that one which involves the greatest 
responsibility, — the keeping count of the sponges used and making 
them balance with the number issued, so that there can be no 
possibility of one remaining in the abdomen. This responsibility 
is shared with her by the sponge and supply nurse, but the final 
burden of whether or not a sponge is missing lies with her. She 
must see that the surgeon does not close the abdomen with a 
sponge remaining therein, unless he so does upon his own re- 
sponsibility after due warning. 

This nurse, in addition to her duties towards operator and 
patient, should bear in mind the fact that the anaesthetist may 
need her assistance. She should be ready to anticipate his wants 
and to help him if called on in a sudden emergency. The ordinary 
emergencies which the anaesthetist may have to meet in the 
course of an operation are three in number: (1) Obstructed 
breathing, indicated by cyanosis of the face. This may be due 
to the tongue or jaws dropping back, or to accumulation of mucus 
in the throat. The remedy is to lift the lower jaw up, to draw 
the tongue forward, and to wipe out the mouth and throat with 
a swab of gauze on a clamp. (2) The patient may stop breathing, 
due to central paralysis. There are three common measures used 
to meet this emergency: artificial respiration, rhythmic traction 
of the tongue and lowering the patient's head. Artificial respira- 
tion may be done by the Silvester method (see Chapter XXIX) 
or by the Marshal-Hall method, which consists in compressing 
the lower segment of the ribs by the hands placed on either side. 



318 THE OPERATION 

This forces the air out and the natural expansion of the ribs draws 
the air in. It is not so efficient as the Silvester method and far 
less efficient than the Shafer method, but the latter is not avail- 
able with the patient in the dorsal position on the operating table, 
Rhythmic traction on the tongue (Laborde's method) consists 
in seizing the tongue with forceps, drawing it out of the mouth, 
and alternately making strong traction and relaxation at the 
rate of about fifteen times a minute. This acts as a powerful 
stimulant to the respiration. (3) Shock or collapse may occur, 
particularly towards the latter part of a prolonged operation. 
Its approach will be indicated by pallor of the face, rapid pulse, 
shallow respiration and lowered blood-pressure. The measures 
used to combat this condition are numerous. The principal ones 
are: (a) a hypodermic injection of one of the stimulants contained 
in the hypodermic tray; (b) elevation of the foot of the table to 
allow blood to gravitate to the head; (c) warm salt solution 
sometimes with coffee given by rectum; (d) infusion of normal 
saline into a vehi, under the skin of the breast or thighs, or 
directly into the abdominal cavity through the wound; (e) arti- 
ficial warmth ; (/) bandaging the extremities so as to emptj^ them 
of blood in order that the brain may have all the blood that can 
be given it. Both arms and both legs should be bandaged from 
the toes and fingers to the trunk. Flannel, gauze or muslin 
bandages may be used. The bandages should be applied with 
even pressure, but very firmly. No padding need be used under 
them. 

2. Instrument and Suture Nurse. — It is the duty of this 
nurse to apply the sterile covers to the instrument table and to 
arrange upon it the instruments when they are brought to her. 
She is to arrange them in an orderly manner so that she can 
have them promptly as required. She must have the various 
suture materials threaded in suitable lengths and sizes upon 
suitable needles when they are needed. Finally, as she becomes 
more experienced, she will find that anticipation of commands 
has succeeded compliance to them and that she has eveiything 
at the hand of the surgeon or the assistant without the need of 
any warning that it will be required. And this attainment 
marks her entrance as an integral part of what should be a perfect 
and harmonious machine working together for the best interests 
of the patient. 

3. Sponge Nurse. — This nurse, being the least experienced 



PREPARATION FOR AN OPERATION 319 

of the operating-room staff, is given that position which, while 
in no way inferior in importance and responsibility, requires less 
intimate knowledge of the various steps in the technic of the 
different operations at which she may attend. In outlining her 
duties, we will assume that the precaution (so necessary in every 
well-conducted operating room) of putting up all supplies for 
operating use in definite quantities has been observed. She 
arranges her sterile towels, covers, sponges, packers and dressings 
upon the table (which, as with the instrument table, has a sterile 
cover) in an orderly manner that will enable her to supply the 
articles required with promptitude. She will open packages of 
sponges only as required for use, making a careful count of the 
contents of each package as opened to see if its contents agree 
in number with the routine. She will remember how many of 
each article she has issued to the operator and convey this infor- 
mation to the unscrubbed nurse, upon demand. She will see 
that all packers are wrung out of hot sterile salt solution before 
being passed to the operator; that they have haemostats or some 
other identifying mark fastened to the tapes; and will keep the 
same careful count as of sponges. The grave responsibility 
assumed by this member of the operating staff, although shared 
by others, should be constantly in her mind and prevent any 
lapse that may be regretted when the time for prevention has 
passed and naught but regret is left. 

V. CARE OF THE ANESTHETIZED PATIENT 

This particular aspect of the subject of surgical and gynaeco- 
logical nursing must, necessarily, begin in the ward before the 
patient starts for the operating room. Steps must there be taken 
to foreguard the patient from exposure to draughts and chilling 
on the way to the operating room and also on the table during 
the first stages of anaesthesia. The body should be protected 
by a warm gown and the limbs by clean Canton flannel or woollen 
leggins. The patient should then be warmly wrapped in blankets 
for transportation to the operating room. The patient should 
be transferred from the carriage to the table in the same coverings 
that she wears to the room. All of the many forms of operating 
table in use at the present time are primarily designed, as they 
should be, for the convenience of the operator, but it is unfortu- 
nate that in most cases the comfort of the person lying on the 
table is not thought worthy of even secondary consideration. 



320 THE OPERATION 

In the anaesthetized patient all the muscles are completely re- 
laxed, and in this condition he is peculiarly liable to injury from 
lying for a long time in a strained and unnatural position. Two 
points are especially to be remembered. If an arm or a leg is 
allowed to hang over the side of the table (Fig. 118), pressure of 
the sharp edge will inevitably cause a painful injury, from which 
the patient will suffer acutely for many days. If one of the 
large nerve trunks happens to lie in the line of pressure, paraly- 
sis of the muscles supplied by it will follow which may not be 
recovered from for weeks or months. Pressure from straps or 
upright posts attached to the table may also be responsible for 
injuries of this kind. 




Fig. 118. — Position for breast operation, showing improper position of arm resting on 
edge of table. Arm should be held by nurse to prevent pressure. 

The curve of the back where it does not touch the table 
should be property supported by a cushion or pillow. Without 
this precaution the relaxed and unconscious patient is subjected 
to severe strain of the spinal ligaments and muscles, and this is 
exaggerated when, as in gall-stone operations (Fig. 119), a hard 
support is placed under the lower ribs, if the small of the back 
is not supported at the same time. From this cause patients 
often suffer agonizing backache for days after an operation. 
The temperature of the operating room should be kept be- 
tween 75° and 85° F. to prevent any danger of chilling. Dur- 
ing the progress of the operation, those parts of the patient 
that are not necessarily exposed for operative purposes are 
kept warmly wrapped and covered in blankets. In some of 



PREPARATION FOR AN OPERATION 321 

the hospitals, this desirable end is additionally sought by 
the use of a hot-water cushion for the top of the operating 
table. The operation being completed and the dressings applied, 
the patient is once more warmly wrapped throughout with warm 
blankets and returned to her bed. Before leaving the operating 
room, any wet places are wiped dry and any wet clothing is 
removed, to preclude the possibility of the patient being per- 
mitted to remain in the ward in wet clothing. 

VI. APPLICATION OF THE FIRST DRESSING 

Before removing from the operating table, the first dressing 
(that will, ordinarily, remain in place from ten days to two weeks) 



^ —*•=£■ 




Fig. 119. — Pillow support under back for operation on gall-bladder. 

is applied. This consists of sufficient sterile gauze to thoroughly 
cover and protect the wound and its immediate vicinity and 
absorb any discharges that may occur. The gauze may be 
arranged in pads or the loose form described as fluffs or handker- 
chiefs. In an abdominal operation this dressing is held in place 
by from two to four strips of two-inch adhesive plaster, the number 
of strips depending upon the length of the wound. Care should 
be taken that the lowest strip of plaster (that nearest the symphy- 
sis) is placed far enough down to fully cover and keep covered the 
lower angle of the abdominal wound. Where it is expected that 
frequent redressings will be necessary, as in infected cases, instead 
of the solid adhesive strip, small strips are fastened at the sides 
with tapes attached to permit their being tied across the dressing. 
This dressing being applied, the patient is lifted from the table, 
the back wiped dry and the patient laid upon the carriage, the 
21 



THZ OPERATION 

abdominal binder being already in place upon the carriage. The 
binder is then brought across in front and pinned with safety 
pins, darts being made in the sides frith a ifety pins to make the 
::z::t: z: —.:- -.^i^y ; : ;_ • z"~zly As :ir ;:;::^: ^izz;' 
has a tendency to slip up r it is well to apply a towel or strap of 
some kind, running from the side of the binder around the thigh 
in a loop and returning to be fastened at its starting point. With 
such an anchor applied on each side, it will be impossible for 
the binder to work up around the waist upon the return of the 
patient to bed, as is not infrequently the case with the ordinarily 
applied binder. 

VTL CARE OF THE PATIENT AFTER OPERA"! : \ 

The gowm if wet. is now removed, the patient warmly wrapped 

in blankets that have been kept heated during the operation 

and returned to her becL The patient should be accompanied 

on the return trip from the operating room to the ward by a 

physician, as a precaution against any sudden emergency arising 

on the trip and causing trouble for the lack of a physician's 

presence. When the patient is returned to her bed, she should 

r.hout a nurse in constant attendance until she has fully 

reacted from the anaesthetic. While under the effects of an 

anaesthetic, it would be a very simple matter for the patient to 

draw particles of vomitus into the air passages and become 

aspL set up an aspiration pneumonia, as the result 

of neglect. It is. also, not infrequent for patients to give the 

Lences of post-operative shock during this period, with 

the natural consequence that neglect of immediate remedial 

measures may lead to results of a fatal character. The nurse 

on duty at the bedside during this period should watch the 

-rit carefully, keeping an accurate record of the pulse and 

I riing the general condition. She should have a pus basin 

ve the vomitus and see that the face is kept 

dean and the mouth m partis - mitus. The pus 

i may be placed at the side of the patient's face and when 

vonri1 _• ;rs the patient's head and shoulders should be turned 

I I i side, by means of a hand under the opposite should - 

I the vomitus will be discharged into the basin and there will 
be a minimum of danger from aspiration of particv - 



CHAPTER XXIV 
SELECTION OF INSTRUMENTS 

The selection of instruments for operations (while ordinarily- 
included in the duties of the assistant) not infrequently devolves 
upon the operating-room nurse. Owing to individual preferences 
on the part of different operators, it is impossible to prescribe 
hard-and-fast rules regarding the instruments used, but there 
are, however, fairly definite sets used in certain procedures. 
Variations from these, while numerous, may be considered as 
unimportant and, in the case of staff surgeons, easily learned. 

1. Dissecting Set (Fig. 120). — In practically every cutting 
operation, the dissecting set is the first employed. This consists 
of one or more scalpels; two dissecting forceps (one for operator 
and one for the assistant) ; two scissors (straight and of medium 
size) ; half a dozen small clamps (artery forceps) ; needles (either 
straight or curved, round or cutting, according to the preference 
of the operator) ; needle-holders (generally two where the opera- 
tion is at all extensive); and sutures and ligatures. In dissec- 
tions of somewhat extensive character, retractors should be 
added to this list. 

With the above enumerated list of instruments as a basis, 
we may gradually build up the larger groups necessary for more 
extensive operations. 

2. General Abdominal Set. — This outfit may be considered 
as a dissecting set, sufficiently augmented (Fig. 121) to permit of 
an exploration of the abdominal cavity. The number of artery 
clamps is increased to twelve. To these are added six medium- 
sized, curved clamps. In addition to the smaller-sized dissecting 
forceps, one long thumb forceps is included for the proper placing 
of pads for packing off the intestines and for such other uses as 
may require intraperitoneal manipulation. The retractors are 
increased by the addition of sets of two larger sizes than those 
used in ordinary dissections. The needles must include some 
fine, round ones for visceral repair and the suture material should 
include (for the same purpose) fine catgut, fine silk, or fine linen 
thread — possibly all three. This may be considered a set that 
will suffice for an exploratory laparotomy, but that must be 

323 



-- 



THE OPERA 7 




SELECTION OF INSTRUMENTS 325 

supplemented from one of the special abdominal sets, dependent 
upon the condition that is expected or may be revealed during 
the exploration. 

With this as the basis for abdominal work, we can proceed 
to the sets formed around it for operations upon special regions 
and conditions. 

3. Appendix Set. — The instruments necessary for operation 
are identical with those of the general abdominal set, with one 
or two possible additions. There may be (in addition to the two 
dissecting forceps already mentioned) one smooth thumb forceps 
for use in inverting the stump of the appendix. It is possible 
that a special clamp may be used for crushing the appendix 
before amputation and an actual cautery (either Paquelin or 
electric) for cauterizing the stump. 

4. Gallbladder Set (Fig. 122).— The gall-bladder set, also, 
is identical with the general abdominal outfit, certain additions 
being necessary for operations upon this organ. There should be 
a trocar and cannula, especially adapted to evacuating the gall- 
bladder. There should be scoops (or dull curettes) devised for 
the purpose of removing stones from the gall-bladder and ducts. 
A long, malleable probe for exploration of the ducts should also 
be at hand. 

5. Stomach and Intestine Set (See Fig. 101). — For operations 
upon the stomach and intestines, practically the only additions 
to the general abdominal set are the specially devised clamps for 
use in operations upon the gastro-intestinal canal. The character 
of the operation and the expressed preference of the operator 
will decide the number and type of clamps used. 

6. Kidney Set. — Operations upon the kidney require little 
variation from the general abdominal set. The needles preferable 
for kidney suture are round. In case of nephrectomy, large, 
heavy clamps will be desired for clamping off the pedicle before 
removing the kidney. Heavy silk will probably be subsequently 
required for a ligature. Any of the usual suture materials, as 
plain or chromic catgut, kangaroo tendon, silk, silkworm-gut, or 
silver wire, may be used in closing this incision as any of the 
others in surgical procedures. 

7. Pelvic Set (Fig. 123). — The instruments required for pelvic 
(gynaecological) surgery are primarily the same as those for any 
general abdominal work, with such additional articles as may be 
indicated by the particular procedure in view. In the simpler 



THE OPERA 7 




SELECTION OF INSTRUMENTS 327 

operations, such as those for displacements, the only instrument 
absolutely necessary, beyond the general abdominal set, is one 
of those designed for seizing and elevating the uterus — a double 
tenaculum, a volsellum, or a uterine elevating forceps. With 
increasing gravity of the type of operation, the variety in instru- 
ments is only along the line of the addition of longer, heavier 
scissors and clamps. For a panhysterectomy for non-malignant 
condition, two long-handled scissors (one straight and one 
curved on the flat) and six long, heavy clamps (either straight or 
curved, as preferred by the operator) should be added. If the 
hysterectomy is on account of malignancy, two of Wertheim's 
right-angled hysterectomy clamps should be added and the num- 
ber of medium-sized, curved clamps increased from six to twelve. 
The retractors should be of the largest size available for deep 
exposure. 

8. Hernia Set. — The instruments for a simple hernia are 
identical with those for general work. The larger sized retractors 
are, generally, not needed, as is also the case with the long abdomi- 
nal thumb forceps. It is well to add a grooved director and a blunt 
dissector, as these instruments are required by some operators. 

9. Extensive Dissecting Set. — In operations requiring ex- 
tensive and careful dissection (such as those performed for the 
radical cure of a malignant growth of the breast, or a complete 
removal of the glands of the neck) the routine dissecting set, as 
originally outlined, must be considerably augmented. The set 
for a radical breast operation has been described as " a dissecting 
set, plus all of the artery forceps in the instrument case," and 
this may be accepted as fairly accurate and almost equally 
applicable to an extensive neck dissection. It is also well, in 
those cases, to add a blunt dissector. 

10. Rectal Set. — The instruments required for operations 
upon the anus and rectum will necessarily vary considerably 
with the type of operation to be performed. The basis, however, 
of this set (as of the others so far considered) is the ordinary 
dissecting set. For any operation upon the interior of the rectum 
or anus (through the anal orifice), some type of rectal speculum 
should be added to the dissecting set. Beyond this, the supple- 
mentary instruments must depend on the operation and route 
chosen. 

A. For Hemorrhoids (Fig. 124). — Where the operation is to 
be by clamp and actual cautery, most of the instruments of the 



328 



THE OPERATION 




SELECTION OF INSTRUMENTS 329 

dissecting set are superfluous. Neither knives, scissors, artery- 
forceps nor sewing materials are ordinarily required, although it 
is quite customary to have them ready in case of failure on the 
part of the cautery. The routine set would be a rectal speculum; 
two dissecting forceps; six small hemorrhoid forceps; one large 
hemorrhoid pedicle clamp; and an actual cautery. If the opera- 
tion of ligation and excision is chosen, the simple dissecting set 
(with the addition of a rectal speculum and, possibly, two or 
three medium-sized curved clamps) will suffice. This same set, 
augmented by an additional half-dozen haemostatic forceps, will 
suffice for the Whitehead operation. It is well to have salt 
solution irrigation ready for intrarectal operations of this type. 

B. For Fissure or Fistula in Ano. — In either of these condi- 
tions, the dissecting set need be augmented only by the addition 
of a rectal speculum, a grooved director and a curved (sharp, 
blunt, or probe-pointed) bistoury. 

C. For Resection.- — Any resection of the lower bowel (by no 
matter what method or route) is bound to adhere more or 
less closely to the type described under extensive dissection. 
Practically the same set of instruments may be used, augmented 
by a blunt dissector and (if approached by the sacral route) also 
by certain instruments from the bone sets. These latter will 
probably be a Gigli saw, periosteal elevator and bone-cutting 
forceps. 

11. Female Perineal Set (Fig. 125). — For the repair of lacera- 
tions of the female perineum, the usual dissecting set is once 
more the basis of selection. To it may be added six extra artery 
forceps, six medium-sized curved clamps and the right and left 
Emmett scissors specially designed for this work. Where a 
special type of needle (as the Peaslee, Reverdin, Ashton, or 
Hirst) is not employed, several fairly heavy, curved cutting 
needles should be supplied for the heavy, perineal sutures and a 
lighter, full-curved cutting needle for the intravaginal sutures. 
The suture materials most commonly used are silkworm-gut, 
chromic gut and kangaroo tendon. 

12. Uterine Curettage Set (Fig. 126).— For curettement of 
the uterus, the following instruments are necessary: perineal 
retractor or vaginal speculum; volsellum, or double tenaculum 
forceps, or single tenaculum; uterine sound; small and large 
uterine cervical dilators; sharp and dull uterine curettes; uterine 
dressing forceps; scissors, and sponge holders. 



330 



THE OPERATION 




SELECTION OF INSTRUMENTS 331 

13. Trachelorrhaphy Set. — As repair of the cervix is generally- 
preceded by curettage, the trachelorrhaphy set is formed by 
combining the curettage and dissecting sets. 

14. Perineal Prostatectomy Set. — For perineal prostatectomy 
by Young's method a greatly augmented and supplemented 
dissecting set is necessary. The artery clamps should be increased 
to twelve or eighteen. Six medium-sized curved clamps should 
be added. In addition, there should be: three or four sizes of 
Young's prostatectomy retractors; two sizes of Young's prostatic 
lobe forceps; one Young prostatic tractor; one Young prostatic 
enucleator; and a metal urethral sound of suitable size. 

The preceding groups, while not exhaustive, may be con- 
sidered a fairly accurate general sketch of the types of instru- 
ments selected for use in those common operations upon the soft 
tissues that fall within the realms of general surgery and gynaecol- 
ogy. The following groups will apply to the surgery of the bony 
tissues and will (in their turn) make no pretence of being the 
only (or necessarily the best) selection of instruments for any 
particular operation. The effort will remain one to indicate an 
adequate selection that will be elastic to the demands of individual 
preference on the part of the operator. 

15. Cranial Set (Figs. 127 and 128).— The instruments 
required for operations within the skull are: (1) those necessary 
for the scalp incision; (2) those necessary for opening the skull; 
and (3) those necessary for the intracranial work. These require- 
ments will be met by a dissecting set in which the artery clamps 
are increased to twelve; an elastic tourniquet, for the control 
of hemorrhage; a cyrtometer for accurate location of the proper 
area; and the special bone set. This latter consists of a periosteal 
elevator; trephining set; Hudson cranial set; rongeur forceps; 
Gigli saw; chisels; and mallet. The Hudson cranial set includes 
a brace; several burr drills of different sizes and shapes; a fine 
dural separator; and a cranial rongeur forceps. Such instruments 
as may be required for the intracranial work vary so widely 
with the kind of operative procedure and individual preference 
that it is impossible to indicate them in this place. In those 
operating rooms where a great deal of brain surgery is done, the 
routine of the operator is soon mastered. In others, the operator 
should be asked to select such special instruments as he may 
desire. 

16. Amputation Set (Fig. 129). — The amputation set may 






THE OPERA 7 




SELECTION OF INSTRUMENTS 



333 




Fig. 130. — Joint resection set. (1) Periosteal elevator; (2) chisel; (3} mallet; (4) lion- 
jawed forceps; (5) tourniquet; (6) saw (Satterlee's) ; (7) Gigli saw; (8) rongeur forceps; 
(8) sequestrum forceps; (10) haemostatic clamps; (11) small curved Kelly clamps. 

vary from the very meagre outfit necessary for amputation or 
disarticulation of fingers or toes to the very extensive selection 
necessary for an amputation in the upper part of the thigh, or 
the Berger shoulder-girdle amputation. In the first-mentioned 
group, a dissecting set and a metacarpal saw or bone-cutting 
forceps will answer all requirements. In the more extensive 



334 



THE OPERATION 




SELECTION OF INSTRUMENTS 335 

operations, these instruments are only the beginning. The first 
requirement is general hsemostasis, which is attained by an 
Esmarch (or other) tourniquet, sometimes supplemented by the 
use of Wyeth's transfixing needles. The dissecting set being 
the basis of the selection for work upon the soft tissues, the artery 
clamps are increased to eighteen in number and augmented by 
twelve medium-size curved clamps. To this set, add one or 
more large amputating knives. Hypodermic syringes and cocaine 
solution should be prepared for blocking off large nerve trunks 
before severing. For the bone work, saws (a Gigli wire saw and 
one of the butcher type); bone-cutting forceps; rongeur forceps; 
and lion-jawed holding forceps will be required. The needles 
and suture materials will depend upon the preference of the 
operator. In general, heavy silk is used for tying large vessels; 
catgut on full-curved cutting needles of moderate size for muscular 
and other subcutaneous sewing; and interrupted silkworm-gut 
on large, medium-curved cutting needles for skin suture. 

17. Wiring or Plating Set. — For the wiring or plating of 
new or old ununited fractures the same reinforced dissecting 
set (already enumerated for amputation) is used. To this are ■ 
added a periosteal elevator; bone-cutting and rongeur forceps; 
drills; heavy silver wire; bone-plates (Lane or Halsted) and 
screws; bone clamps, or lion-jawed forceps; and screw-driver. 

18. Resection Set (Figs. 130 and 131).— The instruments 
necessary for the resection of joints are contained in the combina- 
tion of the amputation and wiring sets. 

19. Osteomyelitis Set (Fig. 132).— The operations for differ- 
ent forms of osteomyelitis (whether acute or chronic) practically 
always consisting in a radical removal of more or less extensive 
portions of the bone involved, the instruments necessary are 
included in the augmented dissecting set enumerated for amputa- 
tion and such bone-cutting instruments as may be required. 
The bone set for this purpose will ordinarily consist of a periosteal 
elevator; a mallet; three sizes of chisels; three sizes of gouges; 
three sizes of curettes; and two or three sizes of rongeur forceps. 



CHAPTER XXV 
OPERATIVE STEPS 

Practically every operator of large experience has a fairly 
definite and exact method of approaching each operation. The 
details may vary, but the succeeding order of the steps is almost 
invariable. In order to be a really intelligent assistant, the nurse 
passing instruments must, in the first place, be familiar with the 
general outline of the operative technic for the different regions 
and. after that, with the order in which each surgeon requires 
the instruments for the next step. It is not intended to convey 
the idea that the nurse must know what ought to be done and 
how to do it. but rather what the operator is going to do and 
with what instruments he will do it. 

With certain general regions, the initial steps of the various 
operations are practically identical, so far as the nurse's duties are 
concerned. The immediate location of the disease condition (as 
well as its character) may vary considerably — thus affecting the 
site and character of the operative work. But this does not, 
ordinarily, call for any change in the instruments. Eor example, 
practically every abdominal operation (whether upon the gall- 
bladder or stomach, vermiform appendix or sigmoid flexure) 
will be inaugurated with the opening of the abdomen and the 
exposure of the contents of the field of operation. For this 
purpose, the operator will need a scalpel and toothed dissecting 
forceps, artery forceps, sponges, scissors and retractors. There 
should be added an additional dissecting forceps for the assistant. 

In taking up the subject of operative steps, an effort will 
be made to present a number of the more general and important 
operations of general surgery and gynaecology, step by step, 
with an enumeration of the instruments that will be needed by 
the operator for each step. The operations will be considered 
in three general classes (operations upon the head; operations 
upon the trunk; and operations upon the extremities) and one 
or more operations considered, in detail, under each class. 
336 



OPERATIVE STEPS 337 

I. OPERATIONS UPON THE HEAD 
Under this class, only one operation will be considered. 

A. Trephining, or Craniotomy, for Intracranial Hemorrhage: 

Step 1. — Localization of area. 

Required instrument: cyrtometer. 
Step 2. — Skin incision. 

Required instruments: scalpel; two tissue forceps; 
six fairly heavy artery forceps; and gauze sponges, 
two at a time. 
Step 3. — General haemostasis. 

Required instrument: elastic cranial tourniquet. 
Step 4. — Freeing of skin and periosteal flap. 

Required instrument: periosteal elevator. 
Step 5. — Cranial resection. 

Required instruments: trephines, or Hudson's cra- 
nial set; Hay's saw, or Gigli saw; rongeur forceps; 
and dural separator. 
Step 6. — Intracranial haemostasis. 

Required instruments: small gauze sponges, one at a 
time; four small artery clamps; free, fine catgut 
(or silk) for ligature; fine catgut (or silk) on fine, 
curved, round needle for ligating suture, in case 
free ligature is not used; a needle-holder; and 
suture scissors. 
Step 7. — Closure of incision. 

Required instruments: four fairly heavy, curved 
cutting needles, threaded with silk or silkworm-gut; 
two needle-holders; two tissue forceps; and suture 
scissors. 

A variation in this method of closure is that advocated by 
Dr. Cushing, where a number of straight, round needles (threaded 
with silk or linen) are used to transfix and approximate the wound 
edges. After proper approximation and haemostasis have been 
thus accomplished, the sutures are drawn through, one at a time, 
and tied. When this method is used, a dozen needles (or more, 
should the length of the incision require them) should be threaded 
in readiness. 

II. OPERATIONS UPON THE TRUNK 

Under this branch of operative work, a number of operations 
will be selected that are typical of procedures in the different 
regions. It is not possible, of course, to describe, in detail, 
every operation that can be performed upon the trunk. It is 
hoped, however, that those described will give a sufficiently 
accurate general idea of the procedure to enable the nurse to 
readily grasp the details of these and other related operative 
procedures. 
22 



338 THE OPERATION 

A. Resection of Portion of Rib for Empyema (Thoracotomy) : 
Step 1. — Incision. 

Required instruments: two scalpels; two tissue 
forceps; six artery clamps; small sponges, two at a 
time as required; and small skin retractors. 
Step 2. — Separation of periosteum. 

Required instruments: scalpel; two tissue forceps; 
two small periosteal elevators; and two medium 
curved clamps, or tissue-holding clamps. 
Step 3. — Resection of rib. 

Required instruments: bone-cutting forceps; Gigli 
wire saw and handles; director or carrier for Gigli 
saw. 
Step 4. — Incision of pleura. 

Required instruments: scalpel; two tissue forceps; 
Mayo scissors; and two tissue-holding clamps for 
grasping edges of pleural incision. 
Step 5. — Institution of drainage. 

Required instruments: single, or double, fenestrated 
rubber tube; safety pin for transfixing tube, or 
silkworm-gut, threaded on curved cutting needle, 
for attaching tube to edge of skin incision. 
Step 6. — Closure of skin incision. 

Required instruments: two medium-curved cutting 
needles, threaded with silkworm-gut; two needle- 
holders; one tissue forceps; and one suture scissors. 
B. Operation for Stones in the Gall=bladder (Cholecystotomy, where 
the gall-bladder is incised and drained; Cholecystectomy, where 
the gall bladder is removed; Cysticotomy, Hepaticotomy, and 
Choledochotomy, where the cystic, hepatic, or common bile-duct 
is incised) : 
Step 1. — Abdominal incision. 

Required instruments: two scalpels; two thumb 
forceps; six artery clamps; sponges; straight, blunt- 
pointed scissors; and two tissue-holding clamps for 
grasping cut peritoneum. 
Step 2. — Retraction of abdominal walls. 

Required instruments: two medium and two deep 
abdominal retractors. 
Step 3. — Exposure of field and protection of general abdominal 
cavity. 
Required instruments: long thumb forceps (or long 
curved clamps) ; six long abdominal packers, wrung 
out of salt solution and with artery clamps fastened 
to ends of tapes; and six medium abdominal packers, 
similarly treated. 

This step is common to practically all intra-abdominal opera- 
tive procedures, the variation being in the sizes of the packers. 

Step 4. — Incision and drainage of gall-bladder. 

Required instruments: two round, curved needles, 
threaded with medium silk, for stay sutures; two 
artery forceps to carry needles; one mouse-toothed 
thumb forceps; one straight scissors; and one gall- 
bladder trocar and cannula; gall-bladder spoon. 



OPERATIVE STEPS 339 

Step 5. — Removal of stones. 

Required instruments: short, medium and long 
gall-stone scoops; short, medium and long gall- 
stone scoop forceps; and long probe for searching 
ducts. 

Step 6. — Drainage of gall-bladder. 

Required instruments: two curved, round needles, 
threaded with No. 2 catgut; two needle-holders; 
one rubber tube, about eighteen inches long and 
one-fourth to one-third of an inch internal diameter; 
one toothed dissecting forceps; and one suture 
scissors. 

Step 7. — Closure of abdominal incision. 

Required instruments: two toothed dissecting for- 
ceps; two curved cutting needles, threaded with 
No. 2 catgut; four large, medium- curved cutting 
needles, threaded with silkworm-gut; two curved 
cutting needles, threaded with No. 2 chromicized 
catgut or kangaroo tendon; and one suture scissors. 
C. Removal of Vermiform Appendix. (Appendectomy) : 

Step 1. — Abdominal incision. 

Required instruments: same as for gall-bladder 
incision, with addition of small skin retractors and 
small abdominal retractors. 

Step 2. — Retraction of abdominal wall. 

Required instruments: same as for gall-bladder 
operation. 

Step 3. — Exposure of field and protection of general abdominal 
cavity. 
Required instruments: same as for gall-bladder 
operation, packers being medium and small size, 
instead of large and medium. 

Step 4. — Delivery of appendix. 

Required instruments: two toothed tissue forceps; 
one blunt dissector; two medium-sized, curved 
clamps; and one medium-sized, straight, blunt- 
pointed scissors. 

Step 5. — Removal of appendix. 

Required instruments: Cleaveland carrier, aneurism 
needle, or sharp-pointed artery clamp, for piercing 
meso-appendix; free, No. 2 catgut; scissors; scalpel; 
two cotton-wrapped applicators, one saturated 
with carbolic acid and the other with alcohol (or 
an actual cautery) ; and two medium heavy clamps. 

Step 6. — Inversion of appendix stump and closure of csecal wound. 
Required instruments: two round intestinal needles 
(either straight or curved), one threaded with fine 
silk or linen thread, and the other with fine (No. 00 
or No. 0) catgut; two artery clamps for use as 
needle-holders; two toothed tissue forceps; one 
smooth dissecting forceps, for inverting stump; and 
one suture scissors. 

Step 7. — Closure of abdominal incision. 

Required instruments : same as in gall-bladder opera- 
tion, with addition of small abdominal and small 
skin retractors. 



340 THE OPERATION 

D. Operation for Radical Cure of Inguinal Hernia: 

Step 1. — Skin incision. 

Required instruments: same as for abdominal 
incision in preceding operations, omitting abdominal 
retractors. 
Step 2. — Opening inguinal canal. 

Required instruments: grooved director; scalpel; 
straight, blunt-pointed scissors: two toothed 
thumb forceps; and two tissue-holding forceps. 
Step 3 — Opening of hernia sac. 

Required instruments: same as for Step 2. 
Step 4. — Attempted resuscitation of strangulated intestine 'when 
present . 

Required articles: six large abdominal packers, 
wrung out of hot salt solution, or two towels, 
similarly treated. 
Srz? 5. — Intestinal resection ''when necessary . 

Required instruments : six medium-sized gauze packers 
(or fluffs I wrung out of hot salt solution: four intes- 
tinal clamps, with rubber-covered blades: two 
curved, round needles, threaded with Xo. 2 catgut. 
for controlling mesenteric hemorrhage: scalpel; 
eight artery forceps; four round needles 'straight 
or curved tines led with fine silk or linen thread; 
two round needles, threaded with fine catgut 
(Xo. 00 or Xo. : one smooth and two toothed 
thumb forceps: two needle-holders; and one suture 
sossors small sponges, as required, two at a time. 
8ijei : — Ref air of inguinal rings and canal. 

Required instruments: two toothed thumb forceps; 
two needle-holders: one curved, round needle, 
threaded with fine silk: four curved needles ('cutting 
or round), threaded with kangaroo tendon. Xo. 2 
chromicized catgut, or silk; skin retractors; and 
one suture bose - 
9nsr 7. — Closing of skin incision. 

Required instruments: two toothed thumb forceps; 
two needle-holders; four curved cutting needles, 
threaded with silkworm-gut; one curved cutting 
needle, threaded with Xo. 2 catgut; and one suture 
- -- 

In this closure, the silkworm-gut may be omitted and catgut 
alone used; or silk alone may be used; or a subcuticular suture 
of silver wire may be preferred. 

This step may be preceded by the placing of a rubber tube, 
rubber tissue, or cigarette drain. 

E. Shortening of Round Ligaments, for Retrodisplacement of Uterus 
(Baldy-W 
3 PS 1 and 2. — Same as for gall-bladder operation. 

Required instruments: same as for gall-bladder 
operation. 



OPERATIVE STEPS 341 

Step 3. — Elevation and control of uterus. 

Required instrument: one uterine elevating forceps, 
or one volsellum forceps, or one double tenaculum 
forceps. 
Step 4. — Operation upon round ligaments. 

Required instruments: one toothed thumb forceps; one 
Cleaveland carrier, or sharp-pointed artery clamp, 
for piercing broad ligament and seizing round liga- 
ment; two tissue-holding forceps for holding and 
controlling round ligaments; two curved, medium- 
sized, round needles, threaded with silk or linen 
thread; two needle-holders; and one suture scissors. 
Step 5. — Closing of abdominal wound. 

Required instruments: same as for gall-bladder 
operation. 
F. Supravaginal Removal of Uterus and Appendages (subtotal panhys 
terectomy) : 
Steps 1, 2 and 3. — Same as for round ligament operation. 

Required instruments: same as for round ligament 
operation. 
Step 4. — Freeing of bladder. 

Required instruments: one toothed thumb forceps; 
two tissue-holding forceps; one scalpel; and one 
medium-sized, blunt-pointed scissors. 
Step 5. — Temporary control of hemorrhage and section of broad 
ligaments. 
Required instruments: one toothed thumb forceps; 
six large, straight, toothed clamps (Ochsner clamp) ; 
six medium-sized, curved clamps; and one long, 
curved, blunt-pointed scissors. 
Step 6. — Section of uterus and seizure of cervical stump. 

Required instruments: one toothed thumb forceps; 
one scalpel; one long, curved, blunt-pointed scissors; 
and one volsellum forceps. 
Step 7. — Permanent control of hemorrhage and closure of cervical 
stump. 
Required instruments: one toothed thumb forceps; 
six medium-sized, curved cutting needles, threaded 
with No. 2 catgut (double); two such needles 
threaded with No. 2 catgut (single); two needle- 
holders; and one suture scissors. 
Step 8. — Closing abdominal wound. 

Required instruments: same as for round ligament 
operations. 
Minor Gynecological Operation. Dilatation and Curettage of 
Uterus; Repair of Lacerated Cervix and Perineum 
A. Dilatation and Curettage of Uterus: 

Step 1. — Exposure and seizure of cervix. 

Required instruments: one perineal retractor, with 
weight; and one volsellum forceps. 
Step 2. — Exploration of uterine canal. 

Required instrument: one uterine sound. 
Step 3. — Dilatation of cervical canal. 

Required instruments: one small cervical dilator: 
and one large cervical dilator (Goodell's). 



THE OPERATION 

9ro 4. — Curettage. 

Required instruments: one medium-sized, sharp 
uterine curette; one small, sharp, uterine curette; 
one uterine dressing forceps and narrow strip gauze 
for removal of small particles from uterus; and one 
heavy scissors, for cutting strip gauze. 

B. Repair of Lacerated Cervix (Trachelorrhaphy") : 

Step 1. — Placing of stay sutures. 

Required instruments: one toothed thumb forceps: 
two medium-sized, curved cutting needles, threaded 
with silkworm-gut: two needle-holders: and two 
artery forceps for clamping ends of stay sutures. 
Step 2. — Denudation of cervical scar. 

Required instruments: one toothed thumb forceps; 
and one scalpel. 
9ra 3. — Suture of cervix. 

Required instruments: four medium-sized, curved 
cutting needles, threaded with kangaroo tendon or 
No. 2 chromicized catgut; one toothed thumb for- 
ceps; two needle-holders ; four artery clamps; and 
one suture scissors. 

C. Repair of Lacerated Perineum (Perineorrhaphy^ : 

Bbsb 1. — Placing of stay sutures. 

Required instruments: one toothed thumb forceps: 
three medium-sized, curved cutting needles, threaded 
with silkworm-gut; two needle- holders ; and three 
artery clamps for clamping stay sutures. 
Step 2. — Outlining and denudation of area of laceration. 

Required instruments: two toothed thumb forceps; 
one scalpel: two Emmet scissors (right and left); 
and six artery clamps. 
Step 3. — Suture of angles. 

Required instruments: four medium-sized, curved 
cutting needles, threaded with No. 2 chromicized 
catgut: one toothed thumb forceps: two needle- 
holders; four artery clamps; and one suture scissors. 
9xsr 4. — Suture of perineum, proper. 

Required instruments: four large, curved cutting 
needles, threaded with silkworm-gut: two needle- 
holders; one toothed thumb forceps; four artery 
clamps; and one suture scissors. 
— : ' — kin approximation. 

Required instruments: one toothed thumb forceps: one 
medium-sized, curved cutting needle, threaded with 
No. 2 plain catgut; one needle-holder; and one 
suture so- - 
III. OPERATIONS UPON THE EXTREMITIES 
\. Amputation Through the Thigh: 

Step 1. — Preliminary. Application of the tourniquet. 

Required instruments: one rubber elastic band 
tourniquet or a piece of large rubber tubing, suf- 
ficiently long to encircle the limb several times; 
with this, should be furnished a towel, folded length- 
wise in four thicknesses, and long enough to encircle 
limb under tourniquet. 



OPERATIVE STEPS 343 

Step 2. — Outlining and dissecting the flaps. 

Required instruments: one scalpel; one mouse- 
toothed forceps; one scissors; and six artery clamps. 
Step 3. — Partial division of muscles and exposure of sciatic nerve. 
Required instruments: one amputation knife; one 
scalpel; one toothed thumb forceps; and one blunt 
hook. 
Step 4. — Cocainization of sciatic nerve. 

Required instruments: hypodermic syringe, filled 
with 1 per cent, solution of cocaine. 
Step 5. — Further division of soft parts, down to bone. 

Required instrument: one amputating knife, or one 
scalpel. 
Step 6. — Division of the bone. 

Required instruments: one periosteal elevator; one 
wide muslin retractor, for muscles of stump; one 
bone saw; and one rongeur forceps. 
Step 7. — Securing and ligating blood-vessels. 

Required instruments: one dozen (or more) artery 
clamps — straight and curved; one toothed thumb for- 
ceps; heavy silk, or linen, ligatures; and catgut 
(No. 1 or No. 2) ligatures. 
Step 8. — Suturing the muscles. 

Required instruments: two large, curved needles, 
threaded with No. 2 catgut; two needle-holders; 
toothed thumb forceps; and one suture scissors. 
Step 9. — Closure of skin. 

Required instruments: three (or more) large, curved 
cutting needles, threaded with silkworm-gut; addi- 
tional silkworm-gut; two needle-holders; one toothed 
thumb forceps; twelve clamps for temporary secur- 
ing of ends of sutures; three cigarette or small 
dressed- tube drains; and one suture scissors. 
The instruments and sutures for this step must, 
necessarily, vary widely with the individual prefer- 
ences of different surgeons. 
B. Disarticulation at the Shoulder: 

Step 1. — Incision of skin and muscles. 

Required instruments: one scalpel; two toothed dis- 
secting forceps; one scissors; two skin retractors; 
and artery clamps as required, at least two being 
constantly at hand. 
Step 2. — Incision of capsule of joint and division of muscle 
attachments. 
Required instruments: the same as for Step 1, with 
addition of periosteal elevator. 
Step 3. — Ligation of main vessels. 

Required instruments: same as for Step 1, with addi- 
tion of blunt dissector; and an aneurism needle 
threaded with strong silk, or linen ligature. 
Step 4. — Cocainization of main nerve trunks. 

Required instruments: same as for Step 1, with addi- 
tion of one blunt dissector; one blunt hook; and a 
hypodermic syringe filled with 1 per cent, cocaine 
solution. 



344 THE OPERATION 

Step 5. — Division of remaining tissue. 

Required instruments: one amputating knife, or 
scalpel, and one toothed dissecting forceps. 
Step 6. — Securing and ligating blood-vessels. 

Required instruments: about a dozen clamps, 
straight and curved; and silk, linen, or catgut 
ligatures — as called for. 
Step 7. — Suturing the muscles. 

Required instruments: two (or more) large curved 
needles, threaded with No. 2 catgut; two needle- 
holders; one toothed thumb forceps; and one suture 
scissors. 
Step S. — Closing the skin wound. 

Required instruments: the same as for the corre- 
sponding step in the thigh amputation. 



CHAPTER XXVI 
OPERATIONS IN PRIVATE HOUSES 

It must be assumed, at the outset, that no hard-and-fast 
rules can be laid down for the preparation for and conduct of 
operations performed in private houses. The means and sur- 
roundings of the patient will be variable, as will the outfit and 
preparedness of the surgeon to cope with such occasions. Our 
effort must, therefore, be to lay down general principles that 
are to be observed so far as opportunity and the surroundings 
permit, and to indicate a few of those measures and makeshifts 
that are of use in the absence of a properly-equipped operating 
room. 

1 . The Room. — A large, well-lighted room should be selected. 
Where attainable (if the operation is to be by daylight), a room 
with a northern exposure is preferable, as this gives an even light 
throughout the day and any of the other exposures is under the 
direct glare of the sun at some hour of the day. All hangings, 
draperies, pictures, rugs, etc., should be removed the day before 
the operation; the walls and floors carefully cleansed (preferably 
being gone over with a cloth moistened in some antiseptic solu- 
tion, either bichloride 1-1000 or carbolic acid 1-100 or 1-20); 
and any superfluous articles of furniture either removed or so 
disposed of as to be out of the way at the time of the operation. 

2. The Table. — It may be accepted, as a general thing, that 
some portable form of operating table will be brought by the 
surgeon. Should this, however, not be the case, an ordinary 
kitchen table may be pressed into service — being carefully 
scrubbed until mechanically clean and then treated by the 
application of an antiseptic solution, in the hope of further 
promoting asepsis. The top of the table may then be covered 
with new oil-cloth or rubber sheeting, which is, in turn, subjected 
to the antiseptic wash. 

3. Utensils and Supplementary Supplies. — In addition to the 
table used for the operation, there must be another table (or 
tables) sufficiently large to permit the proper laying out in an 
orderly manner of the various instruments, dressings and ma- 
terials used in the course of the operation. These tables should 

345 



346 THE OPERATION 

be cleansed and covered in a manner similar to that described 
for the operating table. The instruments and sterile dressings 
will be supplied by the operator. Certain utensils and supplies 
should, however, be on hand and prepared for use before and 
during the operation. Sufficient linoleum, rubber sheeting, oil- 
cloth, or (in case of necessity) newspapers should be at hand to 
cover and protect the floor in the immediate vicinity of the oper- 
ating table. There should be a chair for the anaesthetist and 
(where urethral, vulvar, vaginal, perineal or rectal work is to be 
done) also one for the operator. There should be three clean 
basins (which have been rinsed thoroughly with a strong anti- 
septic solution) and an ample supply of warm sterile water for 
the proper scrubbing of the hands and forearms of the operator, 
his assistant and the nurse. There should be green soap, a 
sterile scrub brush and a sterile orange stick for each of these 
persons. There should be two receptacles, one on each side of 
the table, for the reception of soiled sponges. In addition to the 
articles already enumerated, at least four other basins will be 
required: one each for alcohol and bichloride solution for use in 
preparation of the hands and arms of the operating staff; and 
one each for bichloride solution and hot salt solution to be used 
during the operation. These basins should be sterilized by 
boiling in a wash boiler, or by thorough immersion in an anti- 
septic solution. It is quite possible that, in some cases where 
the surgeon is unusually well prepared for operating under such 
conditions, a number of the above-mentioned articles may be 
dispensed with. But it is equally true that, in operations of 
emergency or where the most complete equipment is for any 
cause lacking, the necessity of various makeshifts may arise. 

4. Artificial Light. — When, for any reason of urgency, the 
operation must be performed by artificial light, complications 
may arise that require great ingenuity for their subjection or 
that even render the question of operation absolutely impossible. 
It can well be seen that it would be almost, if not quite, out of 
the question to perform a delicate abdominal operation in a 
country house by the light of kerosene lamps. And the same 
might well be the case in many gas-lighted city houses. It is 
quite possible that, in a case where immediate operative pro- 
cedure is imperative and transportation to a properly-equipped 
operating room out of the question, the use of a kerosene reflector 
or bicycle lamp, an acetylene bicycle lamp, or even an auto- 



OPERATIONS IN PRIVATE HOUSES 347 

mobile searchlight might be possible. Where electricity is at 
hand, the problem is greatly simplified. Extension sockets are 
common; reflectors easily obtained; and powerful lights readily 
accessible. 

5. Substitutes for Lithotomy Posts. — This subject has been 
fully considered in the chapter upon " Postures/' the adjustable 
post, the sling and the two applications of the sheet as substitute 
for either being there referred to and described. 

6. Kelly Pad. — The Kelly pad is here made the subject of 
particular remark because it has become to be almost universally 
considered a necessity in a large class of operative work and 
because, at the same time, it seems to be the most usual article 
to forget until needed. If a surgeon, in assembling his supplies 
for an operation, forgets anything, it is the Kelly pad. And 
most people would certainly not consider the lithotomy position 
complete without a Kelly pad under the hips. Fortunately, 
however, there are very few of the different articles of equipment 
so readily and easily replaced by the aid of a little ingenuity. 
A most acceptable substitute is made by rolling one (or two) 
bath towels lengthwise; curving them to the horseshoe shape; 
and covering them with rubber sheeting or oil cloth. A news- 
paper roll may take the place of the bath towel. In fact, a 
newspaper, home-made Kelly pad may be manufactured in a 
very few minutes and makes a very acceptable substitute. And 
very few homes are without newspapers, 

7. Anaesthetic. — The choice of the anaesthetic to be used 
does not come under the duties or within the province of the 
nurse, but it is necessary that she should appreciate the dangers 
attending the use of ether in the vicinity of a free flame. This 
anaesthetic is more volatile than chloroform and highly inflam- 
mable and explosive. It, therefore, follows that unusual care 
must be exercised in its administration where any exterior cause 
for combustion exists. This caution is necessary, not only as 
regards gas-lights, oil lamps, etc., but extends to the use or 
presence of an actual cautery within close proximity to the 
anaesthetist. 

8. Sterilization of Instruments, Water, Etc. — It may be 
accepted as the general rule for all operators, where the work is 
to be done in a private house, to sterilize their own instruments 
and bring them to the scene of operation in sterile containers. 
There are, however, exceptions to this rule and, at such times, 



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PART VI— SUPPLEMENTARY 
CHAPTERS 



CHAPTER XXVII 

GYNECOLOGICAL DISPENSARY 

In the description of the gynaecological dispensary, an effort 
will be made to outline, as nearly as possible, the ideal arrange- 
ment, and, as this arrangement applies equally to office work, 
the description will have a double application. 

1. Records. — Every gynaecological dispensary should have a 
card-index filing system, by which a continuous record may be 
kept of the patient's condition from the first visit. In the present 
day of large dispensaries, where the gynaecological is only one 
of many branches, this system is almost universal. The patient 
entering a large dispensary is first referred to the central or dis- 
tributing office, where a general diagnosis is made from the 
complaint of the patient, this process merely deciding whether 
she should be referred to the medical, general surgical, gynaeco- 
logical, or other branch of the dispensary. This being decided, 
she is provided with a small identification card, containing only 
the data regarding her name, the branch of dispensary to which 
referred, the date of her first visit and the doctor in charge of 
that particular service. This card she retains throughout her 
course of treatment, presenting it each visit. In addition, she 
is supplied with a larger history card, which is to be used as a 
permanent record in the files, and upon this are recorded her name, 
age, occupation, dispensary number, nativity, address and social 
condition. These data are filled out at the central office, where a 
record of the same data is kept. The patient carries this card 
with her on her first visit to the dispensary, where the attending 
physician adds a full history of the case, with results of examina- 
tion, diagnosis and outline of treatment, filing it in his dispensary 
records and making the necessary notes at subsequent visits. 
In large dispensaries (particularly those of teaching hospitals) 
the history is sometimes taken by the assistant to the physician 
in charge — the patient thus coming to him with all the salient 
points of her condition already outlined and with the important 
question of diagnosis and treatment alone left to him. This 
arrangement requires a suite of four rooms: (1) the general 
waiting room, in connection with the central distributing office; 

351 



352 SUPPLEMENTARY CHAPTERS 

(2) the special waiting room for each branch of the dispensary 
^although this may be dispensed with by a proper apportioning 
of those parts of the general room that are in immediate proximity 
to the different branches); (3) special consultation room, where 
the assistant has his desk and takes the histories of the successive 
patients before they go to the physician in charge; and (T) the 
special examining and treatment room, where the physician in 
charge, the nurse, the examining table and the necessary supplies 
are found. 

Naturally 3 in private practice, the central distributing office 
is lacking. The patient goes from the waiting room to the con- 
sultation room, where the physician makes his own record. From 
there she goes to the examining and treatment room. In this 
case, the function of the central office has been performed by the 
physician who has referred the patient to a gynaecologist for 
special diagnosis or treatment. 

2. The Examining and Treatment Room. — This room should 
be well lighted, both naturally and artificially. The artificial 
lighting should include an electric head-lamp that will make 
possible accurate inspection of the vulva, vagina, bladder and 
rectum. Where gas light is used, a light and head-mirror should 
be at hand — the light placed so as to make its use convenient 
and satisfactory. There should be a desk for the physician, 
with the filing case and writing materials conveniently disposed. 
There should be an instrument case containing the necessary 
outfits for the examination and treatment of the bladder, vagina 
and rectum. Space should be supplied, in the instrument case 
or elsewhere, for a sufficient supply of sterile cotton, sponges 
and dressings. The examining and treatment table should be 
one of the standard types, especially constructed for its purpose 
and of the particular kind preferred by the gynaecologist in charge. 
In connection with this table, there should be a surrounding 
screen to afford additional privacy to the patient and a foot- 
stool that she can use as an aid in mounting the table and that 
the examiner can use as a foot-rest in bimanual, combined 
examinations. There should be at least two chairs, one for the 
patient and one for the physician — and it is better to have more. 
as a gynecological patient i< very likely to be accompanied by a 
friend or relative. There should be a table with all the nece>sary 
instruments arranged upon it and covered with a towel, so that 
a naturally nervous patient may not be rendered more so by 
the sight of glittering instruments. A table with three super- 



GYNAECOLOGICAL DISPENSARY 353 

posed, swinging shelves is best, so that the instruments for 
vaginal, rectal and vesical examination may be arranged upon 
the respective shelves quite independent of the other sets and 
conveniently reached when needed. Another stand should be 
at hand, containing sufficient supplies of the different solutions, 
medicaments, lubricant, etc. A sterile bladder-irrigating appa- 
ratus (whether regular irrigator, irrigating syringe, or ordinary 
funnel and tube apparatus) should be always ready for use. A 
sufficient supply of rubber gloves completes the ordinary equip- 
ment of a properly -conducted gynecological examining and treat- 
ment room. 

3. Instruments. — Every completely-equipped gynaecological 
dispensary should be supplied with all the instruments necessary 
for a thorough examination of the urethra and bladder, the 
vagina and uterus and the rectum and sigmoid. In some dis- 
pensaries it is customary to refer those cases where rectal or 
vesical complications are suspected to the special branch having 
charge of these conditions. Diseased conditions of these three 
regions may, however, be so closely interrelated as to make a 
proper differential diagnosis practically impossible without a 
careful examination of two (or possibly all three) systems. 

The instruments necessary for vaginal and uterine examina- 
tion and treatment are : (1) Specula, which should be of different 
types and sizes, to meet the different demands that may be made. 
There should be two or three sizes of the Sims speculum. There 
should be at least two sizes of the Graves or other good bivalve 
speculum. There should be at least three sizes of the Ferguson 
or other tubular speculum. And there should be a very small 
tubular speculum (possibly a large Kelly cystoscope) for the 
examination of children. (2) Tenaculum (either single or double) 
or volsellum. (3) Uterine sound. (4) Uterine dressing forceps. 
(5) Applicators. (6) Sponge holders. In addition to these 
articles of constant use, there are a number of others, less fre- 
quently required, that should be at hand. In this latter group 
are found the pessaries of various types, graduated dilators of 
the Hanks or Hegar type, and such other instruments of special 
application as may be required by the gynaecologist in charge. 

The instruments necessary for urethral and vesical examina- 
tion and treatment depend largely upon the type of instrument 
used by the gynaecologist. If the Kelly type of cystoscope be 
preferred, the outfit will differ quite materially from that required 
for the electrically-lighted instruments that are used in a water- 
23 



354 SUPPLEMENTARY CHAPTERS 

distended bladder. The instruments required for the Kelly- 
method of examination and treatment are. in addition to the 
head-light or light and head-mirror already mentioned: a 
dilator for the external meatus: several tubular bladder specula 
with obturators; a urinary evacuator; long forceps of the mouse- 
tooth or alligator jaw variety; and a ureteral searcher. Ureteral 
catheters are also generally included in this list, as of occasional use. 

F:r the examination of the lower bowel, a very similar class 
of instruments is required to that used for bladder examination, 
the difference being chiefly a matter of size. The head-light or 
reflector is again required. A conical sphincter dilator, very 
similar m appearance to the urethral dilator, is utilized for gradual 
dilatation of the sphincter prior to the passage of specula. The 
specula should be four in number, varying (unlike the bladder 
specula" in length only. These are a short sphincteroscope : a 
short proctoscope; a long proctoscope; and a sigmoidoscope. 
These respective instruments are particularly adapted to the 
:;n of the sphincter region, the lower rectum, the upper 
rectum and the sigmoid flexure of the colon. There should 
be a long-handled applicator and sterile cotton for use with it. 

The different diagnostic instruments have been enumerated 
- - >me length, because it is important for the nurse who has 
charge of them and who is responsible for their care and prepa- 
d to have an accurate idea of the proper use and grouping 
of the different pieces. All of the instruments mentioned should 
be in readiness in a dispensary or office that pretends to thor- 
oughly cover the field of gynaecological diagnosis and treatment. 
In th - sea where the differentiation from conditions of the 
intestinal or urinary tract must be done in other branches of the 
dispensary, only the instruments for vaginal examination are 
kept in the gynaecological room. 

4. Preparation for Examination. — Even- complete gynaeco- 
logical examination should consist of an examination of the 
abdomen, by inspection and palpation, and sometimes per- 
cuss: d of the vulva, vagina and cervix by 
inspection: examination of the uterus and appendages by 
:ned palpation through the abdominal wall with one 

I and the vagina with one or two fingers of the other hand: 

finally, any indicated examinations of the lower bowel 

and urinary tract. Before taking her position on the examining 

table, the patient should remove her corsets and free any 

:ricting bands about the abdomen or waist. The posi- 



GYNAECOLOGICAL DISPENSARY 355 

tion used for the abdominal examination is the horizontal 
recumbent — the abdomen being thoroughly exposed, but the 
patient protected from undue exposure by draping with sheets. 
The positions used for the vaginal inspection are generally either 
the Sims or the dorsal. The latter is now given the preference 
because it is more readily attained; occasions less incon- 
venience to the patient; and is equally well adapted to the subse- 
quent bimanual combined palpation. The knee-chest position 
is the one generally employed for examination of the bladder or 
rectum with the instruments enumerated above. 

5. Drugs, Solutions, Etc. — This particular part of the dis- 
pensary outfit can, of course, be treated in only the most general 
way — as the routine of treatment must vary markedly with 
individual prejudices and preferences. For the convenience of 
the attending gynaecologist, some solution, as bichloride of mer- 
cury 1-1000 or carbolic acid 1-100, should be read}^ in connection 
with the cleansing of his hands. For purposes of local treatment 
to the cervix, vagina and vulva, such medicaments as iodine, 
potassium permanganate, argyrol, ichthyol, etc., are used in 
solutions of varying strength. A solution of boracic acid (from 
2 to 4 per cent.) is one of the most common for bladder irrigation, 
being frequently followed by the instillation of a solution of 
argyrol or protargol. Whatever the drugs used or the strength 
of solution desired, it should be the duty of the nurse on service 
in the dispensary to see that all supplies are constantly on hand, 
in order to assure prompt and efficient service. 

Draping of Patient for Examination. — For the combined 
gynaecological examination, the dorsal position is the usual one. 
After the corsets have been removed and all constricting bands 
about the waist loosened, the patient is placed on the table in 
this position, — the skirts being drawn well above the hips both 
front and rear. During this process, the patient is covered from 
the waist down by a sheet thrown lengthwise across her. The 
sheet is then gathered in the centre from the lower edge and 
fastened just above the pubes, a towel being placed over the 
vulva. The legs are then draped with the sheet, the ends being 
securely twisted around the feet of the patient. 

While the preceding paragraphs were written as particularly 
applicable to the conduct of a gynaecological dispensary (which 
is the one where the services of a nurse are absolutely indispen- 
sable) , the same general rules would apply to any other service 
to which the nurse might be assigned. 



CHAPTER XXVIII 

EMERGENCIES 
I. ACCIDENTS 

The surgical nurse will very property be expected to know 
how to render first aid in cases of accident with which she may 
come in contact, and she will naturally be the one called upon 
to determine what is to be done when a plwsician is not at hand 
The conditions under which she will then be compelled to act 
will be quite different from those to which her training has accus- 
tomed her. In the hospital ward she is rarely expected to take 
the responsibility in the face of an emergency. Her first duty, 
except in rare instances, is to summon the head nurse, an interne 
or the attending surgeon. When, however, she is asked to 
render first aid in a case of serious accident she will have to 
decide for herself, and at once, what is the best thing to do, and 
she must find a way to do it, usually in the absence of everything 
in the way of material or apparatus which she has been taught 
to believe essential in such a case. The accidental injuries 
encountered will vary infinitely in severity and in kind, and there 
will be an equal variety in the available means for dealing with 
them. The nurse will, perhaps, have to do something which 
she has never done before, but has only seen done by others and 
with every appliance at hand. The natural result will be a good 
deal of mental confusion, leading perhaps to doing the wrong 
thing or to doing the right thing awkwardly and with unnece- - 
delay. The first consideration then is as to the proper habit 
of mind with which to approach a problem of this kind. If the 
mental approach is right, the things to do will unfold themselves 
in the correct logical order and the right thing will be done 
speedily and efficiently. 

In the first place, first aid in an accident is always a temporary 
expedient. We do not have to think at all of what is the proper 
treatment in such case*. The treatment will be undertaken later 
presumably by competent hands and with every needed appli- 
ance available. Our object is to check the immediate harmful 
356 



EMERGENCIES 357 

consequences of the accident, and then to hold the situation in 
statu quo until proper treatment can be begun. In the second 
place, there is always just one thing to be done; i.e., one crucial, 
necessary, immediate thing. Other things may be needed later, 
but there is always one thing to be done first, and we will call 
this the indication. Our mental approach to the problem then 
will be something like this. First we ask ourselves: what is the 
indication, what is the one immediate thing to be done? Next, 
what is the easiest and quickest way to do it? Lastly, we will 
ask what means we have at hand to accomplish the action 
decided upon. If we approach our problem in this manner we 
shall find that the first question will nearly always answer itself 
immediately. A brief consideration will enable us to answer 
the second question, and when finally we turn our attention 
to the available means at hand, it is surprising how easily we 
can find something that will answer the purpose. 

We shall discuss in this chapter very briefly some of the more 
common surgical emergencies which the nurse may at some time 
have to meet, considering them from the standpoint which has 
been suggested, but first a few general indications must be 
presented. 

The fiist is a warning against trying to do too much. Meddle- 
some interference in cases of accident often does great and some- 
times irreparable harm. In cities or in any locality where an 
ambulance or a physician can be summoned at short notice, the 
indication, in a very large number of cases, will be to do nothing 
at all except to see that aid is summoned promptly and to ad- 
minister to the patient's comfort pending its arrival. There are 
practically only two surgical conditions where instant measures 
must be resorted to in order to save life. These are (1) very 
profuse venous or arterial hemorrhage, and (2) arrest of respira- 
tion, as from drowning or electric shock, or asphyxiation from 
inhalation of gas, or external pressure on the throat, or a foreign 
body in the larynx. A third condition, that of profound shock 
or collapse, may also in some cases call for prompt measures of 
relief. We shall reserve our consideration of these until the last. 

II. WOUNDS 

Excluding the presence of active hemorrhage, the indication 
for first-aid treatment of a wound is the application of a sterile 
protective covering or one that is as nearly sterile as possible. 



338 SUPPLEMENTARY CHAPTERS 

The most important thing is to keep the fingers or anything 
that has been much handled from contact with the wound. If 
competent medical aid can be had within a few minutes a wound 
not actively bleeding should be left alone. If a delay of some 
hours is unavoidable a protective dressing must be applied. 
Cleansing of an extensive wound should not be attempted usually 
as a first-aid measure. Clots of blood should not be removed, 
lest bleeding be started afresh. If sterile gauze or cotton is 
not at hand or cannot be quickly obtained from a nearby drug 
store, some substitute dressing must be employed. The thing 
to look for is something that has not been in contact with the 
human or animal skin. For this reason torn articles of clothing, 
while they answer well for bandage material, should not be used 
in contact with a wound except as a last resort. The inner folds 
of a clean handkerchief, towel or napkin that has not been opened 
since it was ironed are fairly sterile and may be placed in contact 
with a wound with a fair degree of confidence that this dressing 
material will not be the means of carrying septic bacteria into 
the wound. Paper from unhandled original packages (toilet 
paper, writing paper) may be used if nothing better is at hand. 
Doubtful materials can be sterilized by boiling in water when this 
is possible, or may be saturated with an antiseptic, bichloride 
of mercury (1—3000) or alcohol (for sm all wounds). Carbolic 
acid, except in very dilute solutions, is unsafe for large dressings, 
and in strong solutions is very dangerous. Most of the commer- 
cial antiseptic solutions are of small value. The best dressing 
for an accidental wound is dry sterile absorbent gauze, and next 
to this is bichloride gauze dressing (1-3000). Bandages 

can nearly always be improvised from torn sheets or clothing. 

as been indicated, cleansing of an extensive accidental 
wound is not a first-aid measure. It should be done within a 
few hours by a competent surgeon, preferably at a hospital where 
everything needed is at hand, and with the patient under an 
anaesthetic. X ssary operative measures will be carried out 
at the same time. Tendons or nerve trunks may require to be 
sutured, and partial or complete closure may be done. A very- 
large percentage of accidental wounds should not be closed. If 
cleansing of the wound is attempted it is best done by flushing 
with sterile normal salt solution. Disinfection of the skin about 
the wound, and also of the wound itself, is most efficiently done 
ual parts of tincture of iodine and alcohol. 



EMERGENCIES 359 

Infection by the tetanus bacillus is a serious danger in all 
wounds infected with dirt from a much-travelled public road or 
from a stable yard. A subcutaneous injection of 1500 units of 
antitetanic serum is an almost certain preventive if promptly 
given. The nurse may regard it as a part of her duty to help to 
educate the public to the conviction that this preventive measure 
should always be employed in such cases. It should be observed 
that superficial scratches and abrasions, so contaminated, are 
not likely to develop tetanus, since this organism will not grow 
in the presence of oxygen. It is the deep wounds, particularly 
those of the punctured variety, that are dangerous. Fourth of 
July accidents have always been peculiarly liable to tetanus 
infection. All such wounds should be laid wide open with 
free incisions by the surgeon, and should never be closed by 
sutures. 

The gas bacillus is another anaerobic organism which may 
contaminate wounds from the same source. It is usually in 
deep and severely lacerated wounds that this organism finds 
favorable conditions for its growth. Once started its develop- 
ment is very rapid. The temperature of a patient so infected 
may rise to 104° F. within twenty-four hours after the injury. 
Free incisions and the use of peroxide of hydrogen are the best 
treatment. The mortality is very high. If the infection is in a 
limb, prompt amputation is usually necessary to save life. These 
measures for the treatment of wounds do not, of course, come 
within the province of the nurse, and are not classed as first- 
aid measures. They have been referred to here in order to empha- 
size the necessity of prompt surgical attention in cases of deep 
punctured or lacerated wounds contaminated with dirt from the 
highway or from horse stables and yards. 

III. BURNS 

The indication is a temporary protective covering, mainly 
for the relief of pain. Strips of gauze, handkerchief linen, or 
paper, wet with a solution of washing or baking soda (a teaspoon- 
ful to a pint of water, boiled), or picric acid solution (1-200), 
answer well. Sterile vaseline, machine oil, olive oil or linseed 
oil may be used. Carron oil, an old dressing for burns, is an 
emulsion of equal parts of linseed oil and lime-water. A dry 
charred burn should not be wet but dressed with a dry sterile 
dressing lightly bandaged. 



360 SUPPLEMENTARY CHAPTERS 

IV. FRACTURES 

1. A compound fracture is one in which there is an open 
wound communicating with the broken bones. Sometimes an 
end of a fractured bone protrudes through the wound in the 
skin. In a compound fracture the first indication is a protective 
dressing for the wound. If the end of a bone protrudes it should 
not be allowed to recede under the skin. Iodine-alcohol disin- 
fection of the skin wound and of the protruding bone is good 
first-aid practice before applying the protective dressing. 

2. For simple fractures, in which there is no wound, and for 
compound fractures after the wound has been dressed the indi- 
cation is fixation of the fractured bones and, if possible, of the 
joint on either side of the fracture by means of some temporary 
or makeshift appliance. The means to be employed will vary 
with the location of the fracture. Clothing should be cut away 
to expose a wound, but as a rule should be left in place over a 
simple fracture, since it supplies good padding for the splints. 
In removing clothing remove from the sound side first; in putting 
on a garment start with the injured side. No attempt is to be 
made to set a fracture, but a limb which is bent at an angle may 
be gently drawn into a straight position. 

3. Fractures at the Wrist. — A palmar splint of wood or 
pasteboard or other available material extending from the base 
of the fingers to the elbow will be required. The splint and also 
the back of the forearm should be well padded and the whole 
secured with a bandage. 

4. Fractures of the Forearm. — A palmar and dorsal splint 
bandaged on not too tightly is the indication. A palmar splint 
fits the palm of the hand and the front of the forearm from the 
base of the fingers to within an inch of the bend of the elbow. 
The width of the splint corresponds to the width of the forearm. 
If a flat piece of wood or pasteboard is employed a half circle 
should be cut out to fit the ball of the thumb. A dorsal splint 
fits the back of the hand and forearm from the knuckles at the 
base of the fingers to the point of the elbow. If made of wood 
or other solid material the splints should be well padded. Two 
flattened rolls of newspaper, or any other paper, make excellent 
temporary splints for a fracture of the forearm. They are even 
superior to wooden splints if skilfully applied. No padding is 
required. A magazine opened in the middle and tied or bandaged 
about the arm will answer very well. Good splints can be made 



EMERGENCIES 361 

of straw or small twigs by tying the material into bundles about 
two or three inches in diameter. The splints may be secured by 
three or four ties or a bandage. A sling must always be impro- 
vised for these fractures. The coat sleeve or shirt sleeve may 
be pinned to the part of the garment covering the front of the 
chest, to answer the purpose of a sling. 

5. Fractures at the Elbow= Joint. — No bandaging or splinting 
should be applied to these fractures as a first-aid measure. A 
well-fitting sling giving smooth support to the forearm and hand 
and to the elbow is all that should be attempted. Any make- 
shift fixation apparatus will be difficult to apply and will rarely 
be satisfactory. A bandage is very apt to cause dangerous con- 
striction at this point even when the operator thinks the bandage 
has been put on loosely. 

6. Fractures of the Upper Arm at the Shoulder, and of the 
Clavicle. — In all these the indication is the same, to fix the arm 
to the body. The hand of the injured side may be placed upon the 
opposite shoulder if this position is comfortable, and the whole 
arm and forearm fixed to the side by a bandage or swathe. In 
other cases the hand and forearm may be supported by a sling. 
A pad made of a folded towel or of paper or any suitable material 
that is at hand is to be placed between the arm and the side. If 
the shoulder injury is, or may be, a dislocation instead of a frac- 
ture, the arm may be held rather rigidly at a certain angle, and 
in this case it should not be forced to the side in a painful position, 
but should be supported and fixed in the position it naturally 
assumes. 

7. Fractures of the Leg, Ankle and Foot. — The best emergency 
splint for a fractured leg is the pillow splint. The leg is placed in 
the middle of a full-sized pillow with the pillow case on. The 
open end of the pillow case lies at the foot. The pillow itself 
extends from the level of the sole of the foot to a short distance 
above the knee. The pillow is then wrapped about the leg and 
edges of the pillow case pinned together. The open end of the 
pillow case is then folded about the sole of the foot and pinned, 
thus supporting the foot. Four pieces of bandage or cord are 
then tied about the pillow, one above the knee, one at the ankle, 
and two between these. The pillow alone will answer, but it is 
much better to lay four splints of wood outside the pillow and 
under the bands, two behind and one on each side. Another 
emergency splint is the blanket splint. A blanket is folded so that 



.■."_i .l. : y i ; :-:.-_7tl; - 

qua! to the distance from just above th- b« * i the 
«e provided equal in length to the 
width of the folded blanket. Each stick is then rolled up in an 
end of the blanket until the two roll? come in contact with the - _ 
one on the outer side and one on the inner side. The splint is 
then tied in pla 7 ar firm rolls of heavy paj>-: i - 

. i other material tied into bundles about three inch- 1 -- in 
diameter, may be bandaged aboir s i zaake a ver , 

splint. 

r -actures of the Thigh. — 7 - the most difficult of 

all fractures to hancL- . : .- -_ .- _ . ■.-. i : : per fixa- 

tion and sapp rt a "_ ' "_- lent can be transport- with 
comfort and without injury. First aid _• . tiiap :~a»oe 

in ti --. Four board splints nmsl e taine _: p -sible: 

one for the back 1 _ r five inches wide and long 

enough to extend from the !»- i Ebx J fch< :_iddle of the calf; 
a long outside splint, four inc-- " - and long enough to extend 
frox_ ill to ta- f the : nother :■:■: " 

: -_.- thigh x B| g enough 1 extend from dm 
to within an inch or two of the perineum. A fourth splint is 
seeded for the front of the ting _-ing from the gi m i 

above the patella. All these r_ "_y padded with folded 

• -■ - r any avalla' a- material They a:- - - fixed 

in place by about four ties about the leg and tfaagfc a - 
pelvis and a broL "_ [ing sh :>uld 

bearranr . of orm well to the 

a-al pun- i limb. If b - .- m l had. 

4ibrc* ft round sticks of thf _ tied 

together - :,nd padded to represent each board. It is 

tauM proper materials 

than - - ■ - proper wmpptmt of i 

ared lim - to obi am, some 

ancient means of fixation mnsi 7 'lace a pillow 

ghs and knees, and a 
smaller pad . - - 

ban;. . . with a blanket swathe 

extending from the w to the middle of the calf, and 

■ and. 
9. Fracture of the Jaw. — A tight bandage from the chin fee I 
top ad fixmL upper jaw is a. 



EMERGENCIES 363 

10. Fracture of the Ribs. — A tight swathe, bandage or strips 
of adhesive plaster about the chest is the indication. 

11. Dislocation. — No attempt need be made to distinguish 
between fracture and dislocation, when there is any doubt. In 
case of any crippling injury to a limb the indication is to give 
the limb fixation and support in the position that is most com- 
fortable for it, until proper treatment can be undertaken. First- 
aid splinting is not required for dislocations, as a rule. 

12. Injuries of the Knee= Joint. — The indication is fixation 
of the joint by a posterior splint, and elevation of the leg. An 
ice-bag may be applied, or cold compresses may be used to limit 
the effusion and swelling, with or without elastic compression 
over the knee by means of a bandage. A pillow splint will 
serve the purpose well as a first-aid measure. 

13. Injuries of the Ankle= Joint. — If severe, an injury of the 
ankle should be treated as a fracture of the leg. If the injury 
is evidently only a sprain, a firm bandage with plenty of padding 
from the toes to the middle of the calf is indicated. 

14. Injuries of the Hip= Joint. — For severe injuries in this 
region the indication for fixation and support is the same as for 
a fractured thigh. Most hip injuries can be safely transported, 
by very careful handling, without the aid of fixation appliances. 

15. Diagnosis of Injuries. — Exact diagnosis need not be 
attempted in doubtful accident cases. It is the obvious injuries 
that call for first aid. The patient will usually be able to tell 
the location and even the character of the injury. An uncon- 
scious patient must be carefully examined to determine the 
extent and character of his injuries before one attempts to move 
him. Gentle lifting and manipulation of each limb in turn will 
usually reveal at once the presence of a fracture or dislocation. 
A serious wound will force itself promptly upon the attention. 
When there is doubt the clothing must be removed or cut away' 
if necessary. Judgment must be exercised, of course, as to the 
severity of the injury. Slight injuries need little or nothing in 
the way of first aid. 

V. TRANSPORTATION OF PATIENTS 

Arrangements for transporting the patient will usually be 
made by the doctor who is summoned. Frequently the patient 
may have to be carried short distances by those who render first 
aid. When a patient can walk with help (that is, when he is able 



i -!4 SUPPLEMENTARY CHAPTER 

to bear part of his weight on the injured foot or legj the one giving 
assistance should stand on the patient's sound side for the same 
reason that a lame man using one crutch or a cane uses it on the 
sound side. For helpless patients some substitute for a stretcher 
must be improvised, by means of boards, a shutter or door, or two 
poles with a blanket or two coats slung between. Those carrying 
a stretcher from each end should be instructed not to keep step. 
Two men carrying a patient in their arms should be instructed 
to keep step. A shuffling walk is the proper gait. 

We come now. finally, to consider the first-aid measures 
which are of the greatest importance because they are life-saving 
in character. The occasions where they must be employed will 
come rarely to any individual, to many not at all, but when the 
occasion does arise it will be sudden and unexpected, and will 
tax to the utmost the presence of mind and resourcefulness of 
the person who is called upon to act. There will be little or no 
time for reflection, and success will depend largely upon clear 
understanding of the situation, and practice of the necessary 
manipulations, so far as possible, acquired beforehand. 

VL HEMORRHAGE 

1. It is assumed that the surgical nurse is familiar with the 
elementary facts about the anatomy and physiology of the cir- 
culation of the blood; the relation of arteries, capillaries and veins; 
the action of the heart, the clotting of blood, etc. Her experience 
in the operating room should enable her to recognize the appear- 
ance of a spouting artery, the darker blood flowing from a vein 
and the general oozing of capillary hemorrhage. We shall first 
enumerate briefly the several methods for controlling hemorrhage 
in accidental wounds: next we shall consider the bearing which 
the location of the wound may have upon the problem of control 
of hemorrhage, and finally we shall point out the indications to 
be followed under the different conditions which may be en- 
countered. 

2. Methods for the Control of Hemorrhage. — T:.- ::. >- 
efficient method for the control of hemorrhage is the ligature. 
A small pinch of tissue at the bleeding point is clamped with 
forceps of one of the several patterns in use. A ligature of sterile 
silk, linen, or catgut is then tied tightly about the tissue under 
the point of the clamp in a double knot. Or the ligature is 
threaded into a curved needle, passed through the tissue under 



EMERGENCIES 365 

the point of the clamp and tied. The latter method is used where 
the tissue is either very friable or very dense. These methods 
are a part of the operative technic and the nurse will see them 
constantly employed during her operating-room experience. 
They are, however, not available ordinarily in cases of accident, 
since the necessary instruments and ligatures will rarely be at 
hand or easily accessible. We must, therefore, as a rule, rely 
upon other methods for the immediate arrest of hemorrhage 
in cases of accidental wounds. These include, first, elevation 
of the part, which has important but limited uses; second, pres- 
sure in some form, the method of greatest importance and widest 
application; and, third, the use of means which either cause 
contraction of the small divided vessels or hasten the coagula- 
tion of the blood.. These latter methods include heat and cold 
and the styptic or astringent drugs. 

(1) Elevation of the Part. — This method is applicable only 
to the hand and arm, or the foot and leg. It is effective for 
venous and capillary hemorrhage, but will not control bleeding 
from an artery, although it somewhat diminishes the force of 
the arterial stream and is therefore of use in conjunction with other 
methods, even in arterial hemorrhage. 

(2) Digital Compression of the Brachial or Femoral Artery. — 
Almost all the blood flowing to an arm or leg can be instantly cut 
off by pressing the main arterial trunk which supplies the limb 
between the fingers and a bony surface. For the brachial artery 
the inner border of the biceps muscle at the middle of the upper 
arm marks the place where the artery can readily be compressed 
against the bone. The hand grasps the biceps with the tips 
of the fingers at its inner border and the thumb on the outer 
side of the arm. The fingers feel for the pulsating artery and 
compress it against the bone. With the arm raised the axillary 
artery can be compressed against the head of the humerus, 
under the anterior axillary fold. These manoeuvres can be easily 
learned by a little practice. The femoral artery can be felt in 
the groin just below Poupart's ligament, where it passes over a 
bony prominence. Strong pressure with both thumbs will usually 
be necessary to control it. Compression of other large arterial 
trunks, such as the common carotid, the subclavian and even 
the abdominal aorta, can be done with the fingers in some cases, 
but is too difficult and uncertain to be recommended to a novice. 

(3) Flexion. — Strong flexion at the knee or elbow, with a 



366 SUPPLEMENTARY CHAPTERS 

small pad between the flexed surfaces, may suffice to check 
hemorrhage from deep arteries in the foot and hand, which being 
protected by the plantar or palmar fascia are sometimes difficult 
to control by direct pressure. 

(4) The Tourniquet. — Many forms of this appliance are 
described in the older surgeries. The only one now in practical 
use in the operating room is the elastic rubber band. An emer- 
gency tourniquet is made from a handkerchief, cravat, belt or 
strip of cloth torn from the clothing, tied loosely about the 
limb, and twisted tight with a stick. Such a tourniquet is to 
be applied only about the thigh or upper arm. It is useless about 
the forearm or leg. It should always be placed at least four 
inches above the injured tissues, and should be applied outside 
the clothing or with some form of padding under the band. It 
should never be allowed to remain in place more than three hours. 

(5) Pressure by a Bandage. — A tight bandage applied over the 
wound dressing will control hemorrhage unless there is bleeding 
from a deep vessel which is protected from pressure by anatomical 
structures, as for example the deep palmar arch in the hand. A 
pressure bandage applied to a limb should extend from the 
fingers or toes up. 

(6) Packing the Wound. — The nurse will probably see this 
method applied during her operating-room experience. The 
essential thing is that every crevice of the wound shall be filled 
with the packing material, so that equal pressure is made over 
the whole of the raw surface. It is not recommended as a first- 
aid measure unless the proper materials are at hand or the 
necessities of the case require it. It involves cleansing the wound. 
Packing is useless in the presence of clots. Sterile materials 
must be employed if possible. 

(7) Direct Pressure. — This means that the thumb or first 
finger, or a small pad held by the fingers, is thrust directly into 
the wound and pressed against the bleeding vessel at the point 
where it is wounded. This is the simplest, easiest and quickest 
method for temporary control of the bleeding from a wounded 
artery or vein. The objection to it in accident cases is that the 
finders are always dirty, in the surgical sense at least, and when 
they are brought in contact with the wound the chances of infec- 
tion arc greatly increased. Accidental wounds are presumably 
always infected, but as a matter of fact many of them will heal 
primarily if they are not handled, whereas nearly all of those 



EMERGENCIES 367 

that are handled will suppurate. The method of direct pressure 
is in constant use in the operating room; the surgeon presses his 
gloved finger or a gauze sponge on the bleeding point even while 
he is reaching for a clamp. In accident cases the method is to 
be reserved for those cases of violent hemorrhage from large 
vessels which must be checked instantly if life is to be saved. All 
risks of infection are, of course, to be disregarded rather than 
let a patient bleed to death. When the bleeding vessel is once 
under the control of the finger, very moderate pressure will be 
fuund to be sufficient, and it can be easily maintained for any 
length of time that is necessary. 

(8) Heat and Cold. — Hot water is the most efficient means 
for the control of capillary oozing. An ice-bag is useful to control 
subcutaneous bleeding. 

(9) Styptic or Astringent Drugs. — These are useful only for 
capillary bleeding. They are not to be recommended in first- 
aid treatment. 

3. The Indications for the Control of Hemorrhage According 
to Character and Location. — In cases of hemorrhage from wounds 
of the extremities or of the scalp we have the consoling thought 
that the bleeding can always be controlled. A tight band about 
the head will check bleeding from a scalp wound, and a pressure 
bandage over the dressing will control it. If there are clots under 
the scalp these should be first pressed out, as pressure will not 
be efficient while they remain. In active hemorrhage from 
wounds of the arm or leg the first indication is elevation of the 
part; the next is digital pressure on the main artery. If the 
bleeding is profuse a tourniquet can then be put on and tightened 
sufficiently to check the flow. With this in place the wound may 
be dressed at leisure and a firm bandage applied. The tourniquet 
can then be loosened, but left in place to be tightened again if 
necessary. 

A ruptured varicose vein may result in a fatal hemorrhage 
in a surprisingly short time (five or ten minutes) if the patient 
remains standing or sitting in a chair. The recumbent position 
wTth elevation of the leg will check the bleeding instantly. A 
small pad bandaged over the bleeding point will control it. 

Superficial wounds of the trunk, except at the points where 
the great vessels pass to the extremities and the head, rarely 
give rise to serious hemorrhage. Pressure bandages over the 
dressing, or sometimes over packing in the wound, are the only 



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the finger k gently withdrawn and a tight gaoze or handkerchief 

" " .'. - '. -""."."-. i.r '." — .- . t. :o -•>." --- "'.:- 7 z r'T-s-or- 
with the hand, or a heavy weight may be placed over it and 

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- :i-^: 



EMERGENCIES 369 

the nerves of the imaginative, or even of the most phlegmatically 
disposed. Safety lies in keeping always before the mind the 
simple fact that the situation is absolutely under control. Even 
a slight muscular effort becomes very trying when continued for 
a long time. Intelligent attention must be directed to minimizing 
fatigue, by avoiding unnecessary exertion in making pressure, 
by slightly changing the position of the fingers from time to time 
so as to shift the effort from one group of muscles to another, 
and sometimes by resting a padded weight upon the hand. 

Hemorrhage from the mucous membranes in the mouth, nose, 
vagina, or rectum is not often severe enough to be immediately 
dangerous. The application of cold externally and of ice water 
within the cavities is the first indication. Hemorrhages from the 
stomach (hsematemesis) and from the lungs (haemoptysis) are 
medical and not surgical conditions. 

VII. ARTIFICIAL RESPIRATION 

The principal indications for the employment of artificial 
respiration are drowning, and asphyxiation by illuminating or 
other gas. To these the most recent industrial conditions have 
added one more, that of electric shock. 

There are two methods of artificial respiration in use at the 
present time, known as the Silvester method and the Shafer 
method. The latter is by far the more efficient. In addition there 
are now upon the market several very efficient machines for the 
production of artificial respiration (pulmotor, lungmotor). 
Most hospitals will be supplied with one of these. In the Silvester 
method the patient lies upon his back, in the Shafer method upon 
his face. For this reason the less efficient Silvester method is the 
one which must usually be employed when respiration fails upon 
the operating table. A patient cannot be turned upon his 
face in the midst of an operation, particularly an abdominal 
operation. In the Silvester method two operators are almost 
essential for efficient work. One on either side of the patient 
grasps an arm and lifts it strongly above the patient's head. The 
two arms are then brought down across the patient's chest, and 
pressure is made on the lower ribs, thus forcing the air out of 
the lungs. The two manoeuvres are repeated about fifteen times 
a minute until the patient begins to breathe naturally. 

Professor Shafer describes his method as follows: "Lay the 
subject, face downward, upon the ground, with the arms stretched 
24 



370 



SUPPLEMENTARY CHAPTERS 



above the head and the face to one side. The operator should 
at once place himself in position astride or at one side of the 
subject, facing his head and kneeling upon one or both knees. 
He then places his hands flat over the lower part of the back 




Fig. 133. — Shafer method of artificial respiration. First position: inspiration; pressure off. 

(on the lowest ribs), one on each side, and gradually throws the 
weight of the body forward on them so as to produce firm pressure, 
which must not be violent, or upon the patient's chest. By this 




Fiq. 134. — Shafer method of artificial respiration. Second position ; expiration ; pressure on. 

means air and water, if any is present, are forced out of the 
patient's lungs. Immediately thereafter the operator raises his 
body slowly so as to remove the pressure, but the hands are left 
in position. This forward and backward movement is continued 



EMERGENCIES 371 

every four or five seconds. In other words, the body of the 
operator is swayed slowly forward and backward upon the arms 
from 12 to 15 times a minute, and this should be continued for 
at least half an hour or until the natural respirations are resumed" 
(Figs. 133 and 134). 

VIII. SHOCK IN ACCIDENT CASES 

If there has been no hemorrhage the shock resulting from an 
accident is a condition akin to exhaustion from great exertion, 
as explained in the chapter on anoci-association. It is due to 
great emotional stress and the direct effect of the trauma upon 
the cells of the brain. Absolute rest and quiet with the applica- 
tion of external warmth are the indications. It is good practice 
to give a small hypodermic of morphia. Whiskey or brandy, or, 
better still, a teaspoonful of aromatic ammonia in water, relieves 
the sensation of faintness, but the supposed efficiency of these 
as stimulants is much in doubt in the minds of many experienced 
surgeons. Calm assurance and confidence on the part of those 
who attend the patient are factors of importance in psychic 
shock. When extensive hemorrhage has occurred another factor 
is added in the condition of shock for which active treatment 
may be required. The position with the head lowered and, in 
bad cases, firm bandaging of the extremities, from the toes to the 
groin, and from the fingers to the shoulder, are indicated in 
order to save all the blood available to supply the brain and the 
heart. Warm saline solution should be given by rectum or 
subcutaneously, the latter, of course, only under strict aseptic 
conditions. 



CHAPTER XXIX 

THE PERSONAL ATTITUDE OF THE NURSE 

The personal attitude of the nurse is so closely dependent 
upon individual characteristics and the demands of particular 
circumstances that it is only with great difficulty that rules, or 
even suggestions, for governing it can be outlined. It is true, 
however, that in her multifarious relations with the hospitals, 
with the individual sufferer, with the public at large and with 
the medical profession, the question as to what her duty is in a 
particular case must often arise. And, necessarily, each of these 
problems must be to some extent related to the duty to self. 
The effort, here, will then be to outline, at times generally and at 
others specifically, what attitude her duty requires in these, her 
several relations. 

I. ATTITUDE TO THE PATIENT 

Of course, the first duty of the nurse (as of the physician or 
the surgeon) is to the patient upon whom she is attendant. 
This duty consists, broadly, in bringing into play all of those 
resources that have, by her training, been placed at her command 
for the relieving of the chscomfort and suffering to which the 
patient is subject. The three cardinal virtues of the trained 
nurse are competency, cheerfulness and reserve. It may be 
safely assumed that the first of these exists in the great majority 
of trained nurses, whether graduate or undergraduate. But the 
other two are only in a degree less important and, probably, 
where not naturally possessed, more difficult of attainment. And 
even cheerfulness, which is in itself a gift, may be quite without 
avail if devoid of the balance of reserve. One may have a ready 
smile; a willingness to perform unceasingly and without complaint 
the numerous small and tiring routine measures for the comfort 
of the patient ; a readiness to put up with minor, or even consider- 
able, discomforts; and a ready flow of interesting conversation 
when the condition of the patient seems to warrant or require 
this diversion. But natural, or acquired, reserve should warn the 
nurse that, at times, silence is more acceptable than the brightest 
conversation; that her conversation should never include the 
372 



THE PERSONAL ATTITUDE OF THE NURSE 373 

interesting (and sometimes morbid) details of other cases; and 
that, above all and before all, any information, no matter how 
trivial, obtained in her professional capacity is under a seal that 
must be absolutely inviolate. 

II. ATTITUDE TO THE SURGEON 

The attitude or duty of the nurse to the surgeon must, neces- 
sarily, bear an intimate relation to her attitude to the patient. 
She must assume that he is competent to outline properly the 
treatment and she must see that his orders are faithfully executed. 
She must keenly and closely observe and record the varying con- 
dition of the patient from time to time, and, in case of emergency, 
see that the surgeon is promptly notified. She must be suffi- 
ciently familiar with the dosage and method of administration 
of powerful drugs to prevent errors of carelessness or ignorance 
in administration. And she should observe absolute and unwaver- 
ing loyalty to the surgeon, where this does not certainly encroach 
upon her first loyalty to the patient. 

This last statement brings up one of the most delicate points 
in the relations of the nurse to her environment. By all just 
reasoning, her first duty is to the patient. But she also owes an 
undoubted loyalty to the surgeon. And besides this loyalty, 
it must be presupposed that the broader education and greater 
experience along these lines of the surgeon will make him better 
fitted to judge of what is best for the patient than can be possible 
for the nurse. Nevertheless, occasions do arise when the compe- 
tent nurse becomes convinced that the treatment outlined for 
the patient is wrong and, possibly, harmful. In this case, wherein 
lies her duty? In hospitals, the responsibility may fairly be 
placed upon the superintendent of nurses and the medical staff 
of the hospital. In private practice, however, the solution is 
not so simple. First, it is difficult for the well-balanced nurse 
to assure herself that her doubts are well founded. Second, if 
she speaks to the patient, without consulting the surgeon, she 
will have been disloyal to the latter, possibly without benefiting 
the patient, who may discharge the nurse and retain the surgeon. 
Third, if she speaks first to the surgeon, she may be discharged 
without opportunity to benefit the patient. The best and safest 
solution of this difficult problem would appear to be: (1) that 
the nurse assume that the surgeon is competent, conscientious 
and correct, until she is forced to a contrary decision; (2) that 



374 SUPPLEMENTARY CHAPTERS 

she then verify by the best means at her disposal her doubts 
preferably consulting some more experienced person, as the super- 
intendent of the training school from which she graduated; (3) 
that she then, if further convinced, inform the family of the 
patient of her doubts and, after this warning, terminate her con- 
nection with the case; (4) that she notify the surgeon of her action; 
and (5) that she carefully refrain from suggesting or recommend- 
ing any substitute or consultant for the regular attendant. By 
pursuing such a course, the nurse will have: (1) avoided acting 
with undue precipitance; (2) performed her duty to the patient; 
(3) avoided the possibility of suspicion of ulterior motive on her 
part; (4) been, at least, honest and open with the surgeon; and 
(5) conducted herself with due regard to decorum. 

It is possibly well to caution the nurse against at any time 
indulging in comment to the patient, whether of praise or of 
criticism, concerning the ability of other surgeons than the attend- 
ant. There sometimes arises, in this connection, a feeling that 
the nurse, for one reason or another (even where no such inten- 
tion exists), desires to create a comparison to the discredit of 
one practitioner, a course which, at best, is as unwise as it is 
discourteous. 

III. ATTITUDE TO THE HOSPITAL 

The nurse, whether undergraduate or graduate, who is en- 
gaged in hospital work, must occupy one of two positions to that 
institution, being either a member of the working organization, 
an integral part of the official family or a guest to whom the 
courtesy of the institution has been extended. In the one case, 
she owes at least community loyalty, and, in the other, an obser- 
vance of the ordinary laws of hospitality. This means that it 
is her duty, so long as she remains within the hospital, to observe 
the internal rules of the institution. Her care of and attention to 
the patient must consider not only those duties that exist from a 
nurse to a patient, but must, also, include an endeavor so to 
perform her duties that no criticism of the hospital may come 
from the patient, as a result of her fault. It is frequently from 
the attention or inattention of individual nurses that patients 
form their opinions of a hospital, and it is upon the impressions 
of these patients that their friends decide as to the merits or 
demerits of a particular institution. It is not desired to suggest 
that a good nurse can offset all the defects of a badly-managed 



THE PERSONAL ATTITUDE OF THE NURSE 375 

and ill-conducted hospital, but it is undoubtedly the fact that a 
careless, inattentive or neglectful nurse may undo the good 
impression that would, otherwise, be left by a perfectly-organized 
institution. 

IV. ATTITUDE TO THE PUBLIC 

The individual who enters upon a career that has for its 
purpose the cure or care of the sick accepts a broader responsi- 
bility than that of conscientious service to each individual sufferer. 
The constant trend of modern advance in the allied forces of the 
medical professions is towards the accomplishment of two ends, 
not in themselves directly aimed at the cure of individual cases: 
(1) the prevention of disease and (2) the early diagnosis of certain 
conditions in which the early institution of treatment offers 
the chief hope of cure. While the nurse cannot be the prime 
factor in either of these movements, her position as a trained 
member of one of the branches of these forces imposes upon her 
a responsibility that cannot well be avoided. Her advice will 
be frequently sought by relatives, friends and even mere ac- 
quaintances. Some of these opportunities, possibly the majority, 
will be outside the relatively narrow field considered in this 
volume, but the nurse whose wise counsel has contributed to the 
early diagnosis of a case of pulmonary tuberculosis, of carcinoma 
of the breast, stomach or uterus; or has, by impressing upon the 
prospective mother the necessity for competent medical super- 
vision throughout pregnancy, aided in forestalling a threatened 
attack of eclampsia, may well feel that she has contributed her 
mite to the grand sum total of the effort of her fellow workers. 

V. ATTITUDE TO SELF 

While the profession of nursing must be largely based upon 
altruism, yet the nurse who utterly neglects herself will soon 
resign, perforce, the care of others. A fair general rule would 
be for the nurse to take as good care of herself as the best interests 
of her patient will permit. If the last case has drawn too heavily 
upon the vitality, do not undertake the care of the next until 
properly recuperated. When working under a steady strain, 
do not depend upon the stimulus of excessive tea and coffee 
drinking for support. If unable to rest when you should, do so 
when you can. Be sure to get some exercise in the fresh air and 
sunshine each day, even though rest seems more desirable and 



376 SUPPLEMENTARY CHAPTERS 

fatigue prevents enjoyment. When the body is under a heavy 
physical and nervous strain, do not make matters worse by adding 
an excessive burden to the digestive tract. Eat what is nourish- 
ing, simple and easily digested, preferably at all times, but 
certainly when on hard duty. 

The keynote to the attitude of the nurse towards any part 
of her work or in any of her relations must be found in her atti- 
tude towards the work itself. If she feels that the work is worth 
while and that her best efforts are none too good for it, there is 
little danger of her falling short in her duty. The chief danger 
seems to lie in the changes effected by the period of training, 
when all of her values must be readjusted so as nicely to maintain 
the balance between the ideal as conceived and the real as prac- 
tised. It is at this time that the ideals may be lost and the real 
nurse hidden under the veneer of cynicism that has become so 
usual a part of the life of to-day. And it is this that we most 
wish to avoid. If there are any attributes that the nurse should 
retain as an essential part of her equipment, the leading should 
be her natural sympathies and her natural or acquired ideals. 
These she should maintain amidst the most repulsive exhibitions 
of disease and the most sordid exhibitions of human degradation, 
retaining them, if necessary, upon no other evidence than that of 
faith alone, " the substance of things hoped for, the evidence 
of things not seen. " 



CHAPTER XXX 

AN EPITOME OF SOME COMMON SURGICAL AND 
GYNECOLOGICAL CONDITIONS 

In this chapter a brief outline will be given of some of the 
more common surgical conditions which the nurse will encounter 
in hospital and private practice. The object sought will be not 
to teach how to make a diagnosis or how to treat a case, since 
these are not within the province of the nurse, but to aid her to 
obtain an intelligent understanding, though necessarily general 
and superficial in character, of the surgical diseases and affec- 
tions which come under her care. Particular emphasis will be 
given to the nursing aspects of the case so far as possible in the 
space available. 

I. MALFORMATIONS AND ANATOMICAL DEFECTS AND 
DERANGEMENTS 

A. Congenital Deformities 

Cleft Palate and Hare=lip. Definition. — In single hare-lip 
there is a cleft of the lip extending into the nostril on one side of 
the mid-line, more often the left. In double hare-lip there are two 
clefts with a projecting mass between (intermaxillary bones and 
mid-lip or prolabium) , attached to the nasal septum. Cleft palate 
is a cleft in the mid-line of the roof of the mouth, either partial 
or complete, and usually coexisting with single or double hare-lip. 

Causes. — Arrested development in early fetal life from un- 
known causes. (Maternal impression is not a cause.) 

Symptoms.— Characteristic deformity; sometimes malnutri- 
tion in infancy from difficulty in swallowing; imperfect 
articulation. 

Treatment. — Correction of the defect by a plastic operation. 
In closing the palate silver-wire sutures will be used. After an 
operation for hare-lip the narrowing of the breathing space to 
which the child has been accustomed may lead to cyanosis or 
even asphyxia if proper care is not exercised. The nurse should 
hold the lower lip down until the child has recovered from the 
anaesthetic if there is evidence that it is not getting sufficient air. 
After an operation for closure of a cleft palate the patient must 

377 



378 SUPPLEMENTARY CHAPTERS 

be placed in a position so that saliva, blood, and mucus will flow 
from the mouth. An infant is held in the lap of the nurse with 
the face down; an older child is placed in a semi-sitting position, 
with the face turned to one side. Later the mouth may be 
sprayed with a mild solution (e.g., dilute Dobell's) if the child 
does not cry or struggle, but not otherwise. Feeding is done with 
a spoon, giving meat or chicken jelly or soft gruels. Swabs of 
cotton or gauze must never be used in the mouth, lest they tear 
out the wire sutures. 

Spina Bifida. Definition. — A congenital cleft of the bony 
arches of the vertebrae in the mid-line of the back, usually in the 
lumbar region, with defect in varying degree of the other tissues 
of the back, resulting in a sacculated protrusion of the structures 
of the spinal cord with its contained cerebrospinal fluid. The 
child is born with a tumor on the back, hemispherical in shape, 
often about the size of a man's fist, sometimes smaller or even 
larger. The tumor is a sac containing fluid, its walls consisting 
of the membranes and nerve elements of the spinal cord, with 
the overlying skin, and communicating with the spinal canal. 
The skin may be thinned to a parchment-like membrane, and is 
frequently ulcerated from chafing and pressure. 

Symptoms. — Characteristic deformity. Sometimes, but not 
always, weakness or paralysis of the legs and of bladder and 
rectum. Pressure on the tumor may cause unconsciousness. 

Treatment. — Operative closure of the defect when possible. 
The prospect of success is always very doubtful. Nursing care 
and constant vigilance are of the greatest importance to protect 
the tumor from injury before operation and from infection by 
soiling with urine and faeces afterwards. Spontaneous rupture 
from injury or ulceration may easily occur, resulting in escape of 
cerebrospinal fluid and usually followed by fatal infection. A 
large ring pad of gauze surrounding the tumor may aid in pro- 
tecting it from injury. 

Other Congenital Defects. — The most common, perhaps, are 
those connected with the genito-urinary apparatus and with the 
rectum. Exstrophy of the bladder, a protrusion of the bladder 
wall through a cleft in the anterior abdominal wall, imperforate 
anus, and defective development of the genital organs occur. 
These subjects are too complex for discussion here. The surgical 
problems involved are difficult and in many cases unsolved. 

Many varieties of congenital deformities are met with. The 



GYNAECOLOGICAL CONDITIONS 379 

most common is club-foot, with inversion of the sole and torsion 
of the whole foot. Congenital dislocations of the hip and other 
joints also occur. These conditions come under the care of the 
orthopaedic surgeon. The treatment is in part operative and in 
part by fixation and support with proper apparatus. 

B. Acquired Defects and Deformities 

Many cases of deformity associated with impaired function 
result from paralysis of certain groups of muscles from injury or 
disease of the nerves supplying them, the deformity being caused 
by the subsequent contraction of the opposing group of muscles. 
The most prolific cause of these conditions is the disease known 
as infantile paralysis (anterior poliomyelitis), an infectious 
disease, caused by one of the filterable organisms, which attacks 
young children particularly. The disease itself has few and 
slight symptoms, as a rule, runs a rapid course, and often passes 
unrecognized. The organisms affect certain areas in the spinal 
cord where the motor nerves take their origin, and the result is 
paralysis, sometimes temporary, but often permanent, affecting 
a varying number of groups of muscles throughout the body, 
most commonly in the lower extremities. The treatment con- 
sists in exercise and stimulation, when possible, of the affected 
muscles after the acute disease has subsided, and in the use of 
suitable mechanical supports to aid function and prevent or 
overcome deformity. Sometimes the tendon of an active 
muscle can be transplanted so as to make it do the work of a 
paralyzed one. 

In scoliosis there is lateral curvature and often rotation of 
the vertebral column, producing marked deformity, due often to 
weak muscles and habitual faulty position while sitting and 
standing during childhood rather than to any active disease. 
The treatment is by gymnastic exercises and mechanical support 
and correction. These cases belong preeminently to the domain 
of the orthopaedic surgeon. 

Rickets (rhachitis) is a disease of childhood affecting the 
nutrition and growth of bone. Resulting deformities, such as 
bow-legs and knock-knee, are sometimes of such a degree as to 
interfere with locomotion and require operative means to correct 
them. 

A great variety of deformities occur as the late result of 
injuries (trauma) which have been improperly or unsuccessfully 



380 SUPPLEMENTARY CHAPTERS 

treated at the time of their occurrence. Thus fractures may 
unite with great shortening of the limb due to overriding of the 
fractured bones, or the bone fragments may unite at an angle, or 
they may fail to unite at all . Joints may lose their mobility, becom- 
ing fixed in one position (ankylosis) ; soft parts maj^ be distorted 
by healing in a wrong position or by extensive scarring. Burns 
by heat or by acids or alkalies frequently cause deformity through 
the contraction of the resulting scar. The accidental swallowing 
of caustic substances, which happens with surprising frequency 
in young children, results, when not immediately fatal, in stricture 
of the oesophagus from cicatricial contraction. These conditions 
are too numerous and varied to be briefly summarized. 

II. FOREIGN BODIES 

When we speak of a foreign body in surgery, we mean the 
presence in any of the tissues or organs of the body of any solid 
inert substance that does not belong there. Thus, a bullet em- 
bedded in the tissues, or a peach-stone lodged in the oesophagus, 
or a pin in the trachea is a foreign body; but so also is a loose 
fragment of dead bone or a stone in the kidney or bladder, 
substances in this case not introduced from without, but formed 
where found as the result of disease. 

Foreign bodies in the air-passages must always be removed. 
Those in the digestive canal commonly pass without harm, but 
sometimes require removal. Foreign bodies embedded in the 
tissues frequently become encysted and remain harmless indefi- 
nitely. In the presence of septic organisms, however, a foreign 
body is apt to cause a chronic suppurating sinus which persists 
until its removal. Foreign bodies left in the abdominal cavity 
after operation (sponges, packs, even instruments) deserve 
particular mention. This accident may happen so easily that 
every safeguard must be employed to prevent it. The accident 
fortunately rarely results fatally, but it is very distressing for 
the patient at the best on account of the prolonged morbidity and 
the necessity for a second operation. It is, of course, in the 
highest degree humiliating for the surgical team, every member 
of which should bear the full burden of the responsibility. The 
surgeon must know that he has left nothing behind. The sponge 
nurse must account for every piece of gauze that has been used 
and the instrument nurse for every instrument before closure of 
the wound. 



GYNECOLOGICAL CONDITIONS 381 

III. TRAUMA 

Definition and Causes. — Trauma means a wound or injury 
produced by external violence. The causes are, of course, 
innumerable, and the injury may vary from a mere scratch to 
any degree of severity. 

The Lesions of Trauma. — The essential thing in trauma is 
what is called a solution of continuity in the tissues; i.e., a sepa- 
ration as by cutting or tearing of structures which are normally 
united. So fine is the network of tubes and channels by means of 
which the cells of the body are normally kept bathed in fluid 
that even the slightest wound means the rending of some of these 
blood or lymphatic " vessels," as they are called, with a consequent 
escape of fluid into the surrounding tissues or externally, and 
the primary lesions of trauma are all associated with this escape 
of fluid. If the skin is divided there will be external hemor- 
rhage more or less profuse and of three varieties. In arterial 
hemorrhage the blood is bright red and escapes in forcible, 
intermittent jets synchronous with the heart-beats. In venous 
hemorrhage the blood is dark and flows in a constant 
stream. Capillary hemorrhage is seen as an oozing from the 
whole cut surface. Capillary hemorrhage usually (except in 
bleeders) stops spontaneously within a few minutes, oozing of a 
pale red or straw-colored serum from the wound surface continu- 
ing for many hours. If tissues are injured without division of the 
skin the escaping fluid gives rise to lesions varying according to 
its character and location. Ecchymosis is the escape of blood in 
the deeper layers of the skin with discoloration (the familiar 
"black and blue" spots). A hcematoma is a mass of blood in a 
cavity in the tissues produced by trauma, or a circumscribed 
effusion infiltrating and distending the spaces in the loose cellular 
tissue, particularly that under the skin. The blood clots and 
forms a swelling of varying size and density. (Edema is an effusion 
of serous (watery) fluid through the walls of the capillaries into 
the intercellular spaces and is often seen as the result of trauma, 
e.g., in sprains. There is a swelling which has a dough-like feel 
to the touch, and the skin over it is paler than normal. Another 
form of swelling known as emphysema, due to the distention of the 
tissue spaces with air or gas, is occasionally seen in wounds of the 
lung and in gas bacillus infection. Severe or even fatal hemor- 
rhage may occur into the great serous cavities of the body (the 
peritoneal, pleural, or pericardial cavities) or into the intestinal 



382 SUPPLEMENTARY CHAPTERS 

canal without escape of blood from the body, and this is known 
as concealed hemorrhage. Abrasions and blebs or blisters are 
surface lesions familiar to even' one. 

Wounds of Special Structures. — Wounds of the skin and 
subcutaneous tissue and of the muscles are relatively insignificant 
(apart from hemorrhage and infection*, even when very extensive. 
Wounds of veins and arteries are serious in proportion to their 
size and in accordance with the promptness with which means of 
checking hemorrhage are applied. Wounds of the larger vessels 
are necessarily fatal unless instant help is given. Ligation of the 
main blood-vessels of a limb is, as a rule .with some exceptk 
followed by the formation of a collateral circulation to supply the 
part with blood. In suitable cases closure by suture of a wound 
in a large blood-vessel can be done with restoration of the normal 
blood-channel. Wounds of the heart have been sutured with 
recovery of the patient. A cut tendon results in permanent loss 
of function unless the divided ends are sutured. Division of 
nerve-trunks results in immediate paralysis of the muscles whose 
function they control and in anaesthesia of areas of skin supplied 
by them. Nerve-trunks should have their divided ends accurately 
united by suture, this being followed by restoration of function 
after some months. In wounds of the larger vital organs (brain, 
lungs, heart, liver, kidney) the primary dangers are from hemor- 
rhage, either from loss of blood or (in the brain) from the 
pressure by clots. In penetrating wounds of the serous cavities, 
including joints, and in wounds of the hollow viscera (stomach, 
intestines, bladder, etc.; the most serious danger is from 
infection. Fractures are wounds of bone, usually with displace- 
ment and laceration of the surrounding soft parts and a hematoma 
at the seat of fracture. Fractures are known as simple when 
the skin is unbroken; compound when the fracture communi- 
cates with an open wound; comminuted when there are many 
fragments; and impacted when the broken ends are wedged 
together. Simple fractures have no mortality, but always a 
long morbidity. Compound fractures, not infected, heal like 
simple fractures. If, however, infection takes place, the mor- 
tality is high and the morbidity (in cases not fatal often indef- 
initely prolonged. Tearing of the ligaments and of the strong 
fibrous capsule which surrounds a joint results in displacements 
of the bony structures which form the joint, i.e.. dislocations. 
"Reduction" or replacement of the joint surfaces in normal 



GYNAECOLOGICAL CONDITIONS 383 

position with fixation and early passive motion of the joint 
results almost always in complete restoration of function. A dis- 
location unrecognized for weeks or months is a very serious matter 
for the patient. Reduction will be difficult (often impossible 
without an open operation) and perfect restoration of function 
dubious. The X-ray should always be used when possible in 
the diagnosis of fractures and dislocations. 

Symptoms and Signs of Trauma. — Obvious visible signs, 
laceration of tissue, discoloration of the skin, local acute swell- 
ings, etc., need not be further discussed. Division of tendons and 
division or injury of nerves are indicated by complete loss of 
power either to make movements of flexion or movements of 
extension at one or more of the joints below the seat of injury. 
With nerve injuries there will often be definite areas of insensi- 
bility of the skin as well. In fractures of the upper arm (humerus) 
the power to move the fingers, and the sensation on the back of 
the hand, should always be tested at the first inspection to 
detect a possible nerve injury. If a main artery is occluded, 
pulsation will be absent at the usual points where it is felfc below. 

The two most obvious signs of fracture are crepitus (the 
grating sensation conveyed to the finger by the rubbing together 
of the broken ends of the bone) and abnormal mobility at the 
seat of fracture. Where these are absent, as in fractures near 
joints, and in a fracture of one bone only of the forearm or leg, 
special points of tenderness on pressure on the shaft of one bone 
or near the joint suggest a strong suspicion of fracture. Disloca- 
tion is always to be suspected where there is abnormal fixation of 
a joint with more or less deformity. 

Symptoms of Trauma in Special Regions. — In injuries of the 
head the most important point to be determined will be whether 
there is a depressed fracture or hemorrhage within the skull 
causing pressure on the brain. Paralysis of the arm on the side 
opposite to the injury is a positive sign of pressure in certain 
areas of the brain. Bleeding and, later, a serous discharge from 
the ear indicate fracture at the base of the skull. In other cases, 
persistent headache, mental dulness, and an abnormally slow 
pulse are suggestive of pressure. Characteristic changes in the 
retina soon appear in cases of intracranial pressure, which can be 
recognized by an examination with the ophthalmoscope, which 
must, of course, always be made by a specialist. 

In injuries of the thorax, fracture of ribs will be indicated by 



5GFPUE2 [ENTTARY 3HaPXI 

sharp pain in the ad : breathing; wool I we pleur: 
sputtering of air in the wound: wounds of the luw . 

up of bloc 1 Al dominal injuries never Hie most 

aerio-^ nc wound* ;: baqge vrarefc lea idmg to bobcc nor- 

rhage. and wounds or ruptures : hollow vw.-:: — .w -- " pc 
their con' en1 rig in pen w _ : t m - I :hese 

: ww w^ ::- given -. — where wapte: XATI . Ir_ ^ - - -- 
injur, bdomen <:: pelvis bloc intihe nine should 

1 for and the patient shoul I be <: -a: : „ . : 

urine is delay« a rupture of the bladder be overlo. he 

sngpdcion of intestinal wounds must lead fa 
operation withow waiting i \ synuj - 3 w 

General Principles in the Treatment of Trauma. — The primary 
indications which t _ - - n gsm will endeavor to meet in w - w 
ment of an injury wiD : _ nioixhage : pre- 

Tention of infection, if tihei e h an open won I -..- 

displaced tissues and structures to their normal relation - : : -: 
-.ble. and fixation of the injured part when tins can lone. 
! :.t therapeutic agent in the treatment of trauma is 
revention of movement and prevention :: the . 
function. L re xoration of fun si : the 

joints involved, must be aided by passive ar: 
which should : ~ - 

- it will not be hindered by I - In the 

ease of an injured limb, elevation is important to aid tw red 
circulation, and all tension should i led eitlw 

or bandages. Water should be given freely after injui 

. - ]se - where. 

Quman b I endure and * 
from trauma is amazing. If hemorrh: _ 

troi ram the most 

appalling rid dismembernw 

Burns. — The nature and v - at burns have aim 

~ ace the burden of care from the frequent 
dressing- hen necessary in these - - - metimes falls 

upon the nu: _ wen her- si the] 

- - honld be ifisturbed as little 
ns should n I 
adherent dressing 

should be kept d In burns 

about a joint, healing should not be aDo~~ cur with the 



GYNAECOLOGICAL CONDITIONS 385 

joint flexed. Methods of dressing that waste material and time 
should be avoided. The surgeon will prescribe the dressing that 
is to be used. We will assume, for convenience, that it is a 
boric ointment. Such an ointment is made more efficient in 
preventing adhesions of the dressings if it is made stiffer than 
the ordinary vaseline ointment by the addition of white wax. 
The dressing should be removed with care; it should not adhere 
to the granulations at any point. The granulating surface 
should not be touched. The skin edges may be wiped with a very 
mild solution, preferably sterile salt solution. Carbolic solutions 
should not be used. Every few days, the granulations at the skin 
margins may need burning down with a stick of lunar caustic. 
The ointment will be spread thickly on strips of sterile bandage 
gauze and applied overlapping the whole granulating area. A 
layer of absorbent cotton or gauze is then applied. A roller 
bandage should not be used to fix the dressing, as a rule. It is 
wasteful of material and time. Instead, a swathe made of muslin, 
or even a towel, should be pinned neatly about the part to hold 
the dressing in place. A few spiral turns of a roller may be added 
if necessary for security, and strips of adhesive added to prevent 
slipping. Such a dressing is easily and quickly removed with 
very little disturbance of the patient. 

IV. SURGICAL INFECTIONS 

The Septic Diseases. — Sepsis in wounds and the general 
symptoms of infection have been discussed in previous sections. 
Brief reference will be made here to some of the most common 
forms of septic disease. 

(1) Erysipelas is an acute disease affecting the skin, due to 
infection with the streptococcus; characterized by fever, chill, 
and intense local redness of the skin, with cedema, the eruption 
tending to spread rapidly, and being accompanied with sensa- 
tions of itching and burning. Idiopathic erysipelas, usually 
affecting the face, principally, has a low mortality. Erysipelas 
complicating wounds is frequently fatal. There is no standard- 
ized treatment. The use of antistreptococcic serum has been 
disappointing. 

(2) Diffuse Cellulitis or Phlegmon. — This disease is a septic 
infection involving the subcutaneous cellular tissues. It is 
characterized by great swelling from infiltration, cedematous or 
semi-purulent in character, tends to spread rapidly, and is 

25 




- VPPLEMEXTART CHAPTERS 

- :• institutional symptoms. The primary 

- asuaflv the streptococcus, but the Stophyl- 
also plays an important part a? a secondary 

infection. Eed streaks upon the skin running toward the trunk 
indicate involvement of the lymph-vessels. The hand and aim 
: ~equently the seat of the infection, particularly among men 
who do rough and dirty work with their hands. The skin is 
often undermined with :: i c :~r: ..: .:.t : :^s in the later stages. 
Soughing of subcutaneous tissues including tendon sheaths may 
occur, causing serious disability after the inn animation has sub- 
sided. The treatment - ; y numerous free incisions, moist t 
either in the form : _ ~~ : ire; sings or, better, the continuous bath. 
In this and in all other forms of septic infection the one most 
important medicine for internal administration is water. It is 
i : rn: ugh to give the patient water when he calls for it. The 
: :- ; _:__: see that the patient drink: - :- tei :-r as 

inner • - — Z ~ I-e ; r -Try hour. 

- i ji pus in a cavity which has formed 

in sorir L:oal:Ty :~ tbr .•:■ y so result of necrosis of tissue-cells 

and fiqof&efian. of Hie dead cell-bodies, due to the action of 

"■.:- — - - - : — Zch have invaded the tissues at this point. 

~i z iyl : - - -far the most common offender. The 

:: myriads of leucocytes, which have 
zn£Ti:.e: ir.:-: too :-r: :. o '_._:: .7 :: ii:rz.i~z^ ll::.:.s: zJe> 
. "terncial abscess, the local symptoms will be swelling, 
redness, beat, toetuation, or the sensation conveyed to the 
^■wgMmi-nTnfr finger- : fluid under the skin, and pain with 

:. pressure. Ind- all these, except pain 

iz.i - ■ :. rri'-sf ■..:. r~-: -_.-■-- ;,: -_:_.-» :_..;- ' .-: .. ^r: The 
.■■:.«-.-_-..:.... -:' :ro : --;-> ~_. :.. — ..;> - ; : ■- l: 7:.- 
:::• -:_.■:.- r .:. -. . :. : : :i- ; _r:os-; : lu imff 1^:.:.: ::_ T 
acute in&bunviattary stage, before the abscess has fully formed, 
bo:: i add to the pat: 

(ions. 
The drains used ma; rubber tubing or w game. 

""_.- i : -.:.- .. ----- :■:,-- :y :- :•: ,-;-i- :: ~. .:::_. -y ::. ::_.>s: 
cases. Drainage should be established as ea: i taoble in 

order to arrest the process. Recovery without jnraripnt. is the 
r_>: -:.-:.-: . e o.o ■-:-.:. ioijt 

innammation in bone. The 



GYNECOLOGICAL CONDITIONS 387 

streptococcus, and occasionally the typhoid bacillus, may become 
invaders. The way of access for the invaders is by the blood 
stream, except in compound fractures. There is often a history 
of some previous injury in the region infected. The disease is 
more common in early life. The process of disease is essentially 
the same as in abscess formation in the soft tissues, differing only 
because of the character of the tissue invaded. Necrosis in bone 
results in the formation of large detached pieces of dead bone, 
which may be discharged later or be removed at operation. The 
long bones of the lower extremity are the ones most commonly 
affected. The disease may have a very acute onset, but is often 
very chronic in its development, lasting for years. Later local 
abscesses and sinuses appear with constant discharge of pus and 
occasionally pieces of dead bone. The symptoms are local pain, 
frequently very severe, sometimes worse at night. There is 
usually local tenderness, and redness and swelling may be present. 
Constitutional symptoms are always present and may be mild 
or very severe. The treatment is operative. 

(5) Sepsis in Serous Cavities. — Sepsis of the large joint 
cavities is always a serious matter. The local and constitutional 
reactions are usually very severe. The suffering is acute and 
prolonged and the result disastrous to the joint itself or even 
fatal to the patient. The symptoms are local swelling and pain 
(usually with a history of an open wound of the joint) and the 
constitutional symptoms of sepsis. Prompt operative treatment 
is required. Sepsis in the abdomen (peritonitis) is considered in 
another section. Sepsis in the pleural cavity is known as empy- 
ema. It occurs most commonly following an attack of pneumonia, 
being caused in this case by the same organism (the pneumo- 
coccus). The diagnosis is determined by the physical signs and the 
aspirating needle. The treatment is evacuation of the pus 
through an operative opening, usually with resection of a portion 
of a rib. Recovery is the rule. An important feature of the 
after-treatment is some form of respiratory exercise to expand the 
lung, as by blowing water through suitably-arranged tubes from 
one bottle to another. 

2. Tuberculosis. — This disease, one of the most common to 
which man is subject, is caused by the invasion of the bacillus 
tuberculosis. It is sometimes acute, but usually runs a chronic 
course; may attack almost any tissue in the body; and gives rise 
to a very great variety of conditions of disease. The lesions 



388 SUPPLEMENTARY CHAPTERS 

produced by the organism are of the same kind in a general way 
as those produced by other organisms; i.e., there is local death 
of some cells, with reproduction and increase of other cells in an 
attempt of the body toward defence and repair. In minor ways 
the lesions are different from those produced by other organisms, 
so that they can be recognized. The typical lesion known as a 
tubercle is a minute, grayish-white nodule which can be seen by 
the naked eye in cases of tuberculous peritonitis when the abdo- 
men is opened. In larger masses, necrosis appears in a form 
known as caseation, from its cheese-like appearance. The 
principal forms of surgical tuberculosis are those affecting the 
lymphatic glands and the bones and joints. Large tumors of the 
neck are common from infection of the numerous lymphatic 
glands in this region with this organism. Very extensive opera- 
tions are frequently done for their removal. Tuberculous disease 
of bones and joints results in slow disintegration of the structures 
affected, giving rise to distressing deformities. The treatment of 
these conditions is preeminently not an active treatment, except 
when the destruction of tissue is hopelessly far advanced. It is 
found that, if motion can be prevented and the pressure from 
gravity and from muscular contraction can be removed from the 
diseased bones, recovery will often take place without other aid. 
Prolonged fixation of the diseased area by means of suitable 
apparatus is the most important means of treatment employed. 

V. TUMORS (NEW-GROWTHS, NEOPLASMS) 

Tumors may be defined as new-growths of tissue occurring 
in an organism, which do not themselves perform any function 
and which tend by their presence or by their growth to injure or 
destroy the organism. They may be broadly classified, according 
to their terminal effects upon the organism, as: (1) benign and 
(2) malignant. According to tissue characteristics, they may be 
further classified as: (1) osteoma; (2) myoma; (3) fibroma; (4) li- 
poma; (5) cystoma; (6) epithelioma; (7) endothelioma (the first five 
of which are benign and the last two either benign or malignant) ; 
(8) carcinoma, and (9) sarcoma, both of which are malignant. 

Causes. — The causes of the appearance of the various new- 
growths are not understood. 

Symptoms. — The general and invariable symptom is the 
appearance of an abnormal growing mass in any of the tissues or 
organs of the body. According to the type of neoplasm and its 



GYNECOLOGICAL CONDITIONS 389 

location and manner of growth, there may be varying local and 
general manifestations of its presence. 

Treatment. — The treatment, in general, consists in operative 
removal of the growth. Slow-growing or stationary benign 
tumors, which do not interfere with the functions of the organism 
and have no tendency to malignant degeneration, may be per- 
mitted to remain. In certain of the new-growths, as epithelioma 
of the lip or face and fibroma of the uterus, treatment by the 
Rontgen ray and radium may offer advantages over operative 
interference. 

VI. OTHER ORGANIC DISEASES 

1. Goitre (Struma). Definition. — A goitre is any abnormal 
enlargement of the thyroid gland that is not due to one of the 
benign or malignant new-growths. Goitres may be broadly 
classified as: (1) simple and (2) exophthalmic. 

Causes. — The causes of goitre are not clearly understood. In 
the simple form there is a probability of some water-borne irritant 
being an excitant factor. The exophthalmic type is associated with 
a faulty functioning of the thyroid gland,the cause being unknown. 

Symptoms. — The characteristic symptom common to both 
forms of goitre is the typical enlargement of the thyroid gland. 
This is frequently the only symptom in the simple type; but in 
exophthalmic goitre we have: (1) tachycardia; (2) nervous 
phenomena; (3) exophthalmos, and (4) more or less general 
emaciation. 

Treatment. — The treatment is operative, consisting in the 
removal of such portions of the thyroid gland as may seem 
necessary to the surgeon. 

2* Gangrene (Mortification). Definition. — Gangrene is a 
condition characterized by the death, in mass, of body tissues. 
It may be classified as: (1) moist and (2) dry. 

Causes. —The cause of gangrene may be anything that com- 
pletely destroys the circulation of a part or interferes with it 
sufficiently to prevent proper nourishment. 

Symptoms. — In the moist variety the skin is frequently pale 
and cold at first, assuming a mottled appearance later — either 
purplish or greenish black. There occur: (1) softening of the 
mass; (2) the formation of blisters; (3) an offensive odor, and (4) 
the constitutional symptoms of sepsis. In the dry form there is 
a gradual drying and blackish discoloration of the part, accom- 



390 SUPPLEMENTARY CHAPTERS 

panied by the loss of sensation and the formation of a definite 
line of demarcation between the gangrenous and healthy tissues. 
Constitutional symptoms are not so common as in the moist fonn. 

Treatment. — The treatment is operative, consisting in excision 

imputation in the case of extremities), extending well into 
tissue having an ample blood supply. 

3. Aneurism. Definition. — An aneurism is a sacculated or 
fusiform tumor directly associated with the lumen of a blood- 
vessel and having for its walls those of the vessel. 

Causes. — Aneurisms may be congenital or result from disease 
of or injury to the vessel walls. 

Symptoms. — The invariable symptom is the development of a 
soft, pulsating mass along the course of a large vessel. This, 
depending upon its location, may give rise to varying symptoms 
resulting from circulatory or pressure disturbance. 

Treatment. — The medical treatment consists in rest and 
special medicinal, dietetic, and hygienic measures. The surgical 
treatment, which is particularly adapted to the treatment of 
external (superficial) aneurisms, consists, where possible, in an 
operative restoration of the parts to normal. In other c - - 
complete occlusion, by ligature, of the affected vessel may be 
neeess 

VII. ABDOMINAL CONDITK \ - 

1 . Ulcer of Stomach or Duodenum. Defin Man . — Ulcers of the 

stomach or duodenum are. as the names would indicate, solutions 
in the continuity of the mucous fining of the stomach or the 
duodenum. 

— They probably follow interference with the blood 
supply of the part. Gastric ulcer is more common in females of 
early adult life; duodenal in males between the ages of twenty 
and forty years. Both types are probably influenced by the 
hyperacidity commonly accompanying them. 

Symptoms are frequently absent in gastric and 
duodenal ulcer until the appearance of hemorrhage from either 
the stomach or bowels or the evidences of perforation. The 
usual symptoms are: (1) pain immediately following the ingestion 
of food in gastric ulcer, or one or more hours later in the duodenal 
type; (2) hemorrhage, ani (ysj - raptoms. accompanied 

by nausea and vomiting. 

.iment. — The first treatment may consist of diet and 



GYNAECOLOGICAL CONDITIONS 391 

absolute rest over an extended period. Where this fails, the 
treatment is operative — a gastroenterostomy being performed 
or the ulcer excised. 

Special Nursing Point. — Close watch should be kept for 
evidences of concealed hemorrhage after the performance of 
gastro-enterostomy. 

2. Carcinoma of the Stomach or Intestine. Definition. — 
Carcinoma of the stomach or intestine is a malignant new-growth 
originating in the epithelial elements of these organs. 

Causes. — The predisposing causes may be indicated, in the 
order of their importance, as: (1) age, about 97 per cent, occurring 
after the thirtieth year; (2) heredity, about 15 per cent, of gastric 
carcinoma giving a family history of carcinoma; and (3) previous 
ulceration or chronic inflammation. The immediate cause is 
not known. 

Symptoms. — The usual symptoms are pain, digestive dis- 
turbances, vomiting, anaemia, and progressive loss of weight 
occurring in an individual after the thirtieth year. Progressive 
chronic intestinal obstruction is usually present in the intestinal 
form, and, during the advanced stages of both types, an abdom- 
inal mass is generally demonstrable. 

Treatment. — The curative treatment depends upon an early 
diagnosis and radical operative removal of the entire growth. 
The palliative treatment consists in such measures as may add 
most to the support and comfort of the patient. In addition to 
diet and opiates, surgical intervention may be indicated to relieve 
symptoms of obstruction. 

3. Appendicitis, Intestinal Perforation, and Suppurative 
Peritonitis. Definitions. — Appendicitis is an inflammation of the 
vermiform appendix. It may be classified as: (1) catarrhal, (2) 
ulcerative, and (3) gangrenous. Either of the latter forms may 
progress to perforation and consequent suppurative peritonitis. 

Intestinal perforation is a perforation of all the walls of any 
portion of the intestinal canal. 

Suppurative peritonitis is an inflammation of the peritoneum 
resulting from invasion by one or more species of the pyogenic 
microorganisms and accompanied by pus formation. It may be 
either circumscribed or diffuse. 

Causes. — Appendicitis is a disease of both sexes, being some- 
what more frequent in the male; occurring chiefly in early adult 
and middle life, and depending to some extent upon heredity and 



392 3UPP£EMBBITAK¥ CHAPTER 

diet. The principal sanses its occurrence are r how- 
presence of anatomical defects, foreign bodies, and pathog l:; 
h::t: :rz:.n=zi.= 

Intestinal perforation is usually a result of mflamrx: 
ulceration, or injury. Its most common single cause is m e d f the 
forms of perforative appendic::: 

Suppurative peritoniti a i ; sanaed t y t b e : nt reduction of one or 
::r ; ;: "i 1 zy.-z^zl: — ': ::: :r;ir_:=n= in:-: :i- p-rriv.ii-E-il 
cavi* Hm may be the result, among other causes, of a perforat- 
ing gastric or intestinal ulcer; a perforating or rupturing appen- 
dicitis; or the leakage or rupture of a pyosalpinx. 

Symptoms. — The symptoms of appendicitis in the order of 
their occurrence, are: (1) abdominal pain, usually epigastric in 
locar _ nausea or vomiting general abdominal tender- 

ness, with point of maximum intensity in right lower quadrant, 
I fevei 
The - ym | 1 m a : intestinal perforation may be very indefinite, 
particularly as : » is merely a sequel to a pre 

pathological process. Rupture, or perforation, of the app«^ 
may be followed by hnmediate diminution or ses aatioa of the 
vmptoms, but later gives nee to those of a circumscribed 
or din use sanparative peritonitis. Wh e : e I h - perf orati ; i 

fce : in —herein I tract the symp- 

l) violent pain; (2) abdominal mm 

rigidity anting, and ~ elevation of tempera! 

The last two symptoms are those introducing the suppur 
peritonitis and will be followed, if v mri is is 

abdominal distention and, if circumscribe;: the presence 

of a palpable abse 

r — The treatment of these eondrti 

sting in removal of the appendix, where ac rrhal 

append! d suturing aud dra:: - 

or r : the primary diseased organ, and drainage in the 

other condit: 

— r operation for ai 
purative process in the abdominal cavity, close watch should be 

I for the early symptoms of intestinal obstruction. V. 
nursing any patient where intestinal perforation may occur 

rie or duodenal ulcer, typhoid fever, or appendicitis;, the 
occurrence of sudden abdominal pain should suggest the imme- 
diate summoning of the attending physician. 



GYNAECOLOGICAL CONDITIONS 393 

4. Intestinal Obstruction (Ileus). Definition. — Intestinal ob- 
struction is that condition in which, from any of several causes, 
the intestinal contents cannot pass through that part of the 
alimentary tract situated between the pylorus and the anus. 

Causes. — Intestinal obstruction may be due to: (1) bands or 
adhesions; (2) intussusception, the invagination of one portion 
of the gut into an immediately adjoining section; (3) volvulus, 
twisting of the intestine and mesentery; (4) thrombosis of the 
mesenteric artery, or (5) adynamic ileus, a paralysis of the 
muscular coats of the bowel. 

Symptoms. — The symptoms of intestinal obstruction are: (1) 
absence of bowel movements or the passage of flatus; (2) nausea, 
followed by vomiting, which becomes persistent and may, during 
the later stages, contain fecal matter; (3) abdominal pain; (4) 
abdominal distention; (5) visible peristalsis; (6) rapid pulse; (7) 
thoracic t} r pe of breathing; and (8) elevated temperature in the 
form due to thrombosis of the mesenteric artery, but normal or 
subnormal temperature in the other forms. In intussusception 
a sausage-shaped mass may sometimes be palpated. 

Treatment. — The treatment is operative and varies with the 
immediate cause. An early diagnosis is of vital importance. 

5. Tuberculous Peritonitis. Definition. — Tuberculous peri- 
tonitis is an inflammation of the peritoneum, characterized by 
the formation of numerous tubercles. 

Cause. — The immediate cause is the invasion of the peritoneum 
by the tubercle bacillus. 

Symptoms. — The symptoms are vague. In a typical case they 
would be somewhat as follows: (1) digestive disturbances; (2) 
abdominal discomfort, at times amounting to pain; (3) progres- 
sive general loss of weight; (4) abdominal enlargement due to 
free or encysted fluid, and (5) irregular temperature elevation. 

Treatment. — The operative treatment consists solely in open- 
ing the abdomen and evacuating the fluid. All other treatment 
is dietetic and hygienic. 

6. Hernia (Rupture). Definition. — A hernia, in the sense here 
used, may be defined as any protrusion of an abdominal viscus 
through a normal or abnormal opening. 

Causes. — Among the predisposing causes to hernia, age, sex, 
and heredity all play important parts. The exciting cause may 
be anything that increases intra-abdominal pressure, as sneezing, 
coughing, lifting heavy bodies, or even straining at stool. 



394 SUPPLEMENTARY CHAPTERS 

Symptoms. — The only symptom of a simple, reducible hernia 
is the presence of a soft tumor at one of the normal abdominal 
openings (femoral, inguinal, or umbilical). There may be some 
soreness in the mass. If the mass gives a definite impulse on 
coughing and is easily reducible, it is almost certainly a hernia. 
Strangulated hernia, in addition to the local symptoms mentioned 
above, gives the symptoms of intestinal obstruction. 

Treatment. — In the simple, reducible form the hernia may be 
treated by the application of a suitable truss. Always in the 
irreducible and strangulated forms, and preferably in the simple 
form, the treatment should consist in an operative restoration 
of the parts to normal. In the advanced strangulated form 
intestinal resection may be necessary. 

7. Gall=stone Disease ( Cholelithiasis ). Definition. — Gall- 
stone disease is a condition of the gall-bladder characterized by 
the formation of one or more concretions within its cavity. 

Causes. — The primary sause is probably bacterial infection, 
although obstruction to free drainage and the so-called gall-?- 
diathesis may play an important contributing role. 

Symptoms. — The symptoms are: (1) history of long-continued 
digestive disturbance and probably one or mor- M ks otic; 
_ sudden onset of violent colic -like pain, which us\: 
in from a few minutes to several hours : ana g. In the 

obstructive form (common duct ston^ I audi 5) clay- 
colored stools, and (6) fever are usually added to the preceding 
symptoms. The pain in gall-stone dis< s > ::-equently referred 
backward and upward towards the right shoulder or scapula. 

t. — The treatment is operative, consisting in the 
removal of the stones and drainage of the gall-bladder. 

sing Points. — .After all operations on the bile- 
passages, careful notes should be kept regarding the character and 
amount of drainage and the ■ r and color of stools. 

VIII. EPITOME OF GYN ICAL DISEASES 

The diseased con.Iitions encountered in the care of gymeco- 
_ d patients may be broadly divided into four classes: (1) mat- 
ron':. - md displacement- _ - /.laminations, 
and (4] new-_ - quite us a combi- 
nation of two or more of these condi" occur in a single 
at. 



GYNECOLOGICAL CONDITIONS 395 

1. Malformations and Displacements 

1. Atresia or Stenosis of the Vagina. Definitions. — Atresia 
is the absence or closure of the normal opening. Stenosis is a 
narrowing of the normal opening. 

Causes. — Atresia may be due to a congenitally imperforate 
hymen or to a later adhesion of the vaginal walls, following injury 
or inflammatory process. Stenosis may be congenital or may 
result from the contraction of scar tissue following injury or 
inflammation. 

Symptoms. — The symptoms of atresia would be, in the order 
of their appearance, amenorrhcea, uterine colic of a progressive 
severity as the successive menses are dammed back, and, finally, 
the possible occurrence of reflex convulsive seizures. Stenosis 
would probably give no early symptoms, but would be a subse- 
quent cause of dyspareunia. 

Treatment. — The treatment would consist, in either case, of 
an operative restoration of the parts to normal, the operative 
procedure varying extensively with the location, extent, and 
cause of the condition in each particular case. 

2. Anteflexion of the Uterine Cervix. Definition. — Anteflexion 
of the cervix is an acute bending forward of the uterine cervix, the 
body of the uterus maintaining its normal anterior position. 

Cause. — Anteflexion of the cervix is congenital in origin. 

Symptoms. — Where any symptoms exist, they are those of an 
obstructive dysmenorrhea; namely, uterine colic preceding full 
establishment of flow; frequently clotting of the early flow; not 
infrequently sacral or lumbosacral intramenstrual pain, and 
occasionally pain in the region of the uterine appendages. There 
is generally a slight leucorrhceal discharge. 

Treatment. — The treatment is operative, varying from a 
simple dilatation and curettage to more extensive plastic opera- 
tions designed to straighten the uterine canal by shortening the 
posterior cervical wall. 

3. Retroversion of the Uterus. Definition. — Retroversion of 
the uterus is a swinging backward of the uterine body towards 
the pouch of Douglas, the uterine cervix at the same time swinging 
forward towards the anterior vaginal vault. 

Causes. — Retroversion of the uterus may result from congeni- 
tal causes; relaxation of the intra-abdominal uterine supports; 
destruction of cervical, vaginal, and perineal uterine supports by 



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GYNECOLOGICAL CONDITIONS 397 

prolapse, where the uterus protrudes from the vagina, inverting 
and carrying with it the vaginal wall and forming what is really 
a hernia of the pelvic contents. 

Causes. — The causes may be congenital or acquired. The 
most serious of the latter is destruction of the pelvic floor by 
child-birth lacerations. Increased size of the uterus, accompanied 
by relaxed ligaments and perineal lacerations, would form the 
usual causal elements. 

Symptoms. — The symptom that most usually causes the 
patient to seek medical advice is a protrusion of the cervix from 
the vulva. Accompanying or preceding this, there are apt to 
occur leucorrhcea, a dragging pain throughout the pelvic region, 
backache, and, possibly, dysmenorrhcea. 

Treatment. — The treatment is nearly always operative, al- 
though in the milder degrees the use of tampons and pessaries may 
first be tried. 

II. INJURIES 

1 . Laceration of the Uterine Cervix. Definition. — Laceration 
of the cervix is a tearing of the uterine cervix by the application of 
direct violence. The tear may be unilateral, bilateral, or stellate, 
and usually follows child-birth. 

Causes. — The most usual cause of cervical laceration is the 
passage of the child during labor, although the cervix is occasion- 
ally torn during the process of instrumental or manual dilatation. 

Symptoms. — In the majority of cases there are probably no 
symptoms beyond a slight leucorrhceal discharge. Where the 
laceration is very extensive, it may be contributive to a displace- 
ment of the body of the uterus, and will then be accompanied by 
the usual symptom of such condition. 

Treatment. — The treatment consists in operative repair. This 
is important, even where no severe symptoms occur, as unrepaired 
lacerations are the usual site of carcinoma of the cervix. 

2. Laceration of the Perineum. Definition. — The term "lac- 
eration of the perineum" is used to include any break of the 
tissues at the posterior margin of the vaginal introitus due to 
violence. These lacerations are sometimes classified into three 
degrees for the sake of convenience, the first degree including tears 
of the skin and subcutaneous tissue only, and not really extending 
into the true perineum; the second degree including more severe 
tears involving the levatores ani muscles, but not the sphincter ani 



-"PPLEMEXTAEY CHAPTER 

or rectum; and the third degree including the most severe type, 
those involving the sphincter ani muscle and even the rectal wall. 

Causes. — The vast majority of perineal lacerations are the 
result of child-birth, either following over-distention and conse- 
quent rupture by the passage of the child or by the use of instru- 
ments by the accoucheur. Perineal laceration occasionally 
follows a fall, as on a picket fence. 

— In the first-degree perineal lacerations symptoms 
are usually lacking. In the milder second-degree lacerations the 
same is frequently true. In the more severe second-dr- 
lacerations there are leucorrhcea. constipation, resulting from 
the pouching forward of the anterier rectal wall to produce a 
reetocele. and quite probably accompanying symptoms of pelvic 
congestion due to a more or less marked legree :i uterine descent, 
which frequently follows this destruction of the pelvic floor. In 
third-degree lacerations the symptoms are those : severe 
second-degree tears ombined with incontinence of faeces result- 
ing from the torn sphincter ani muscle and irregular bleeding 
from the everted rectal muc>: s 

7 ■ — The treatment of th A perineal lacera- 

tions which give rise to symptoms is operative and. in the more 
severe cases, requires a higher degree of op^: ' r~- ~~-dll than 
almost any other form of gynaecological surgery. 

III. INFLAMMATIOl 

Pathological conditions of inflammatory naturp may attack 
any of the genito-urinaiy organs and may, starting in one re_ 
spread progressively throughout these systems. It may be 
accepted that, in general, all inflammatory- conditions are evi- 
dences ot the reaction of the organism to the presence of foreign 
bodies. In the vast majority of gynaecological inflammations 
these foreign bodies are of bacterial origin and. consequently, the 
inflammation is the evidence of an infection. Of the pathogenic 
microorganisms, those most frequently found in gynaecological 
infections are the got the B. c s, the strepto- 

■ 'phylococcus, and the B. tuber Of these, the 

gonococcus is much the most frequent cause of serious trouble. 
The- nd staphylococcus appear to be normal 

inhabitants of the vagina, only occasionally causing serious 
trouble, and the colon bacillus is a near neighbor, being a normal 



GYNECOLOGICAL CONDITIONS 399 

inhabitant of the large intestine and occasionally causing trouble 
by migrating to the urinary or genital tract. 

1. Vulvitis. Definition. — Vulvitis is an inflammation of the 
vulva, or external genital organs. 

Cause. — The usual cause of vulvitis is infection with one of the 
pathogenic microorganisms, generally the gonococcus. The condi- 
tion may, however, result from irritating, non-infectious vaginal 
discharges; from urine in diabetic and some other conditions; from 
thread-worms coming from the rectum; or from uncleanliness. 

Symptoms. — First are the classical local symptoms of inflam- 
mation — heat, pain, redness, and swelling. There is more or less 
mucopurulent discharge. There may be constitutional symp- 
toms, as general malaise, moderate fever, and headache. 

Treatment. — The determination of the immediate cause of the 
condition is of the first importance. This may require the 
examination of smears made from the local discharge; of the 
urine, or of fseces. Where the condition proves infectious, the 
treatment is local and general. The local treatment consists in 
maintaining cleanliness by frequent irrigations with a mild 
antiseptic solution and in the direct application of germicides, 
such as argyrol or silver nitrate in solution, or one or more medica- 
ments combined in powder or ointment form. The general treat- 
ment consists of rest in bed, free catharsis, and a fairly free diet. 
Great precautions must be taken to prevent further conveyance 
of the infection. The materials used for applications should be 
burnt. No one else should use the patient's towels or wash- 
cloths. All dressings and napkins should be thoroughly soaked 
in an antiseptic solution before washing. 

2. Vaginitis. Definition. — Vaginitis is an inflammation of the 
vagina. 

Causes. — The causes of vaginitis are identical with those of 
vulvitis, which it frequently accompanies, except that it is not 
likely to accompany diabetes. 

Symptoms. — The symptoms are the same as those for vulvitis, 
except for the greater frequency of constitutional symptoms and 
the presence of a discharge that evidently originates from above 
the vulva. 

Treatment. — The treatment during the acute stage is the same 
as for vulvitis. Absolute rest in bed is possibly of more vital 
importance, as danger of extension to the uterus, tubes, and 
pelvic cavity is more immediate. After the acute stage has 



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GYNECOLOGICAL CONDITIONS 401 

Symptoms. — The symptoms are, in varying degree, those 
already enumerated as characteristic of pelvic inflammatory 
process. 

Treatment. — The treatment of these conditions, during the 
acute stage, is the same as for endometritis. The use of sup- 
portive and anodyne measures is, however, usual — the rectal 
administration of salt solution; the employment of the Fowler 
position; the use of a suprapubic ice-bag, and the hypodermic 
administration of morphine being almost routine. The operative 
removal of the diseased organ or the evacuation of the abscess 
cavity by the vaginal or abdominal route nearly always follows 
the subsidence of acute symptoms, and may be required earlier 
by the appearance or persistence of alarming symptoms. 

IV. NEW-GROWTHS 

In the present discussion of the gynecological neoplasms no 
effort will be made towards either a pathological or organic 
classification or description. We shall consider only three types 
of tumors, and those only as they occur in two organs: cysts of 
the ovaries, and fibroid tumors and cancers of the uterus. 

1 . Ovarian Cyst. Definition. — An ovarian cyst is a tumor 
whose walls consist of the ovary and whose contents are fluid. 

Cause. — The cause of this, as indeed of other forms of new- 
growths, is unknown. 

Symptoms. — The earliest symptom of an ovarian cyst is that 
of almost any disorder of the upper genital tract — irregularity of 
menstruation, either menorrhagia or metrorrhagia. There may 
be pain in the region of the affected ovary, extending down the 
thigh on the same side. Subsequently there is a steadily increas- 
ing enlargement of the abdomen, which may assume enormous 
proportions if permitted to progress uninterrupted. 

Treatment. — The treatment consists in the operative removal 
of the diseased organ. 

2. Fibroid Tumor of the Uterus (Fibroma Uteri). Definition. — 
These tumors, as the name will indicate, are new-growths 
originating in the connective-tissue elements of the uterus. 
When occurring within the walls of the uterus, they are called 
intramural; when just beneath the peritoneal covering, sub- 
serous; and when just beneath the mucous lining, submucous. 

Cause. — The cause is unknown. 

Symptoms. — The first symptom is usually uterine hemorrhage, 
26 



402 SUPPLEMENTARY CHAPTERS 

occurring with or between the menstrual periods and ordinarily- 
becoming progressively more severe. As the growth progresses, 
abdominal enlargement occurs, sometimes as a single mass and 
sometimes as several globular masses. There may be pelvic 
pain; symptoms due to pressure on the rectum and bladder; 
and, frequently, anaemia due to excessive loss of blood. 

Treatment.— The usual treatment is operative — either the 
enucleation of the growth when possible, or the removal of the 
uterus and growth together when necessary. Recently, treatment 
by Rontgen ray and by radium has given promise of encourag- 
ing results. 

3. Cancer of the Uterus (Carcinoma Uteri). Definition. — 
Carcinoma of the uterus is a highly malignant new-growth of that 
organ, arising from its epithelial elements and frequently spread- 
ing to other parts of the body by metastasis. Its most frequent 
and malignant location is in the cervix, usually at the site of an 
old, unrepaired laceration. 

Cause. — The cause is unknown. 

Symptoms. — The more positive and definite symptoms of 
carcinoma of the uterus are usually of such late occurrence that 
their arrival should not be awaited before attempting a diagnosis. 
Any unusual bleeding from the uterus or leucorrhceal discharge 
after thirty-five years of age should lead to a careful examination 
by a competent physician and, in case of further doubt, the 
microscopical examination of exsected tissue. The later symp- 
toms are hemorrhage; offensive, irritating leucorrhoea; pelvic 
pain, and, possibly, bladder or rectal symptoms from the exten- 
sion of the growth. 

Treatment. — The curative treatment consists in early diag- 
nosis and radical operative removal of the diseased area and such 
immediately adjoining healthy tissues as may be safely taken. 
This would include uterus, Fallopian tubes, ovaries, and part of 
the parametrium and vagina. In late cases the palliative treat- 
ment consists in the control of symptoms and the delay of the 
disease's progress by use of the knife, cautery, chemicals, opiates, 
and, possibly, the Rontgen ray or radium. 



INDEX 



Abbreviations, 86 
Abdomen, bandages of, 125 

distention of, with gas, 206 
surgical diseases of, 390 
Abdominal binder, 274 
pads, rack for, 255 
supports, postoperative, 221 
Abscess, 42, 44, 91, 382, 386 
pelvic, 400 
tubo-ovarian, 400 
Absorbable sutures, 264 
Absorption by cells, 10 
Accident cases, hemorrhage in, 364 

transportation of, 363 
Accidental injuries, diagnosis of, 363 

wounds, first aid in, 357 
Accuracy in observation, 190 
Acquired defects and deformities, 

379 
Active and passive congestion, 148 

treatment, 59 
Acute disease, 56 
Adaptation, 16, 29, 65, 69 
in cells, 12 
of parasite to host, 29 
Adaptive changes, 65, 67, 69 
Adhesive plaster, 137, 260, 275 
double-faced (Janus), 260 
for Buck's extension, 138 
for fractured ribs, 141, 336 
in operating-room supplies, 

260 
to apply without kinking, 138 
to fix padding on splints, 136 
to secure fracture dressings, 

137 
to secure wound dressings, 37, 

115, 116, 125, 157, 159 
with tapes, 116, 157 
straps with tapes, 157 
Aerobic bacteria, 49 



Affection, 55, 89 

Air, infection through, 5* 33 

Allis's blunt dissector, 292 

Amputating knives (see Cutting in- 
struments ) 

Amputation set, instruments for, 
331, 332, 333 

Amputations, steps in, 342 

Amyloid degeneration, 81 

Anaemia, 57 

Anaesthesia, 57 

combined local and general, 233 

discovery of, 4 

effect of discovery, 4 

emergencies in, 317 

in exophthalmic goitre, 234 

local, formulae for, 175 

local, with novocaine, 233 

with quinine and urea hydro- 
chloride, 233 
twofold benefits of, 4 
verbal suggestion in, 239, 240 
with nitrous oxide and oxygen, 
231, 233, 238 

Anaesthetic, 31 

dangers from, 317, 347 
in private house, 347 

Anaesthetist, 233, 243, 311, 314, 317 
duties of, in assisting, 317 
equipment for, 311, 312 
nurse as, 233, 244, 315 
responsibility of, 243, 314 

Anaesthetized patient, care of, 317, 
319 

Anaesthetizing room, 246 

Anaerobic bacteria, 49 

Anastomosis, 94 

Anatomical defects, 89, 377 

Aneurism, 390 
needle, 291 

Ankle, fractures of, first aid in, 361, 
363 

403 



404 



INDEX 



Anoci-association, 229 et seq. 

nurse's part in, 234 
Anteflexion of the uterine cervix, 395 
Anterior poliomyelitis, 379 
Antisepsis, introduction of, 6, 95 
Antiseptic, definition of, 298; era, 7 

solutions, formulae for, 175 
Antitetanic serum, 359 
Antitoxins, 76 
Appendectomy, 338 
Appendicitis, 91, 391 
Appendix set, instruments for, 325 
Apron, rubber, 256 
Arm, fractures of, first aid in, 361 
Arterial hemorrhage, 381 
Articulations (see Joints) 
Artificial respiration, 317, 369 
Aseptic era, 7 

surgical technic, 8, 296 et seq. 
wound, 34 
Ashby's vaginal speculum, 238 
Aspirating needles, 294 

care of, 295 
Assembling and handling sterilized 

outfit, 302 
Astringent drugs in hemorrhage, 367 
Atresia of the vagina, 395 
Atrophy, 56, 80 

Attention to bandages and dressings, 
210 
in observation, 190 
Attitude, mental, in meeting emer- 
gencies, 356 
mental, of hospital team, 235 

toward pain, 207 
personal, of nurse, 372 
Auscultation, 58 
Autoclave, 248 

Auvard's vaginal speculum, 288 
Auxiliary instruments, 290 to 295 
dilators, 292 to 294 

Kelly's urethral dilator, 294 
Palmer's cervical dilator, 292 
Pratt-Hank's uterine dila- 
tor, 292 



Pratt's rectal dilator, 294 

urethral sound, 294 

Wale's rectal bougie, 294 

Wathen's cervical dilator, 292 

Weiss's urethral sound, 294 
directors, 292, 293 

plain grooved director, 292 

probe-pointed grooved direc- 
tor, 292 
dissectors, 292, 293 

Allis's blunt dissector, 292 

Massachusetts General Hos- 
pital blunt dissectors, 292 

periosteal elevators, 292 
evacuators, 293, 294, 295 

aspirating needles (explor- 
ing), 294 

Birch's trocar and cannula, 
294 

catheters, 294 

male catheter, 294 

Emmet's ovarian trocar and 
cannula, 294 

female catheter, 294 

H'agner's double-current 
catheter, 294 

Notfs double-current cathe- 
ter, 294 

Ochsner's gall-bladder trocar 
and cannula, 294 

Skene's self-retaining cathe- 
ter, 294 

Tait's ovarian trocar, 294 
searching instruments, 293, 294, 
295 

silver probe, 292 

Thompson's stone searcher, 
292 

Sims's uterine sound, 292 
Axillary splint, 135 
B 
Bacillus, 18, 26 

airogenes capsulatus (gas), 48, 

50, 359 



INDEX 



405 



Bacillus coli communis, 48, 398 

diphtheria?, 20, 31 

pyocyaneus, 48 

tetani, 49, 359 

tuberculosis, 50, 91, 398 
Bacteria, 6, 18, 22, 25, 26, 27 

aerobic, 22 

anaerobic, 22 

colonies of, 22 

color in colonies, 22 

concerned in wound infection, 46 

description of, 18 

distribution of, 26 

facultative, 22 

in air, 5, 26, 29 

in food, 27 

in human body, 27, 45 

in soil, 27, 359 

in water, 26 

in wound infection, 46 

inhibition of growth of, 298 

motility of, 22 

multiplication of, 19 

number of pathogenic species, 25 

pathogenic, 20 

saphrophytic, 20 

septic carriers of, 31, 45, 299 

size of, 19 

spore-bearing, 22 

thermal death point of, 298 
Bacteriology, beginning of, 6 
Balance in cell activities, 17, 60 
Baldy-Webster operation, steps in, 

340 
Bandage, Esmarch, 258 

roller, 273 
Bandages, application of, 114 

attention to, 210 

constriction from tight, 211 

forms and uses of, 111 

materials and preparation of, 
112 

method of rolling, 114 

of chest, method of relieving 
when too tight, 210 



Bandages, pressure from, 117, 210 

swelling of limb below, 117 
Bandaging, for fixation, 116, 139, 140 

for pressure, 118 

for retention of dressings, 114 

principles of, 109, 110 

regional, 122 

turns used in, 118 
Bartlett's metbod of sterilizing cat- 
gut, 269 
Basins for solutions, 254 
Bastianelli's skin disinfection by 

iodine, 305 
Bath, continuous, in local infections, 

149, 386 
Batiste, 273 
Bed, position in, 202 
Belts, postoperative, 221 
Benign tumors, 79, 388, 401 
" Berlin " rinsing curette, 280 
Bichloride of mercury, 22 

formula for solutions of, 175 
Bier's hyperemia, 149 
Binders, postoperative, 221 
Birch's trocar and cannula, 294 
Bismuth paste, 150 
Bistouries, 279 
Bladder, exstrophy of, 378 

irrigation of, 153 

rupture of, 383 
Blake's curette, 280 
Blanket splint, 361 
Blebs, 382 
Blisters, 382 

Bleeding (see Hemorrhage) 
Blood, cells of, 75 

clotting of, 67 

collateral circulation of, 67 
Bodenhamer's rectal speculum, 288 
Boiling water, articles to be steril- 
ized by, 301 
Boils, 91 

Bone-cutting forceps, 281, 283 
Bone wax, Horseley's, 271 
Bow legs, 379 



406 



INDEX 



Brim's gouge. 28 1 
Bucks curette, 280 

extension, 138 
Burns, 63, 380, 384 

first aid in, 359 

open treatment of, 151 
Burr? 27 

C 
Cabot's splint for leg, 135 
Calcareous degenerations, 81 
Calculi _ 

Cancer of uterus, 402 
Cannula? and trocars, care of, . 
Cap, operating- room. _ ' 
Capillary hemorrhage, 381 
Capital operation, 94 
Carbohydrates, 81 
Carbolic acid, 5. 22 

spray as used by Lister, 5 
Carbuncles, 91 
Carcinoma, 80, 388, 391, 402 

oft: 

of intestine, 391 

of stomach, 391 

of uteru-. - _ 
Cardinal signs of inflammation. 42 
Care of anaesthetized patient. _". 
319 

rubber article- I - 

'a urethral speculum, 288 
Carriers of disease organisms, 31, 
- 

of septic bacteria, men and ani- 
mals as. 31, 45, 299 
Carsten's ligature carrier. _ 1 

is degeneration, 81 
Catarrhal appendicitis, 391 
Catgu- 

method of preparing 2 

methods of sterilizing. 2 

plain and chromicized, _ - 

sutures, objections to use o: - 
and ligatures, absorption of, 

_ - 
indications for 287 



Catheterization in female, technic 

of, 152 
Cather -.--.-. 258, _ - see Auxiliary 

instruments) 
Catling knife, 279 

s of disease, 54, 50, 62, 63, 64 
Cell, activities of, 10 

as unit of living matter, 8 

form and structure, 9 

of human tissues, thermal 
death point of, 64 

qualities of, 11 

vital requirements of, 10 
Cell activities, changes 

perverted, 78 
Cellular pathology, 60 
Cellulitis, 385 
Centimetre, English equivalent of, 

170 
Chart- sheet, 180 

description of, 180 

medicine and treatment sheet, 
184 

record sheet, 180 

temperature sheet, 180 
Chemical causes of disea- 

cell activities. 12 

solutions, articles to be steril- 
ized by, 

supplies. _ 
Chest, bandages of. 125 

tight bandagr- 
Chisel and osteotome, difference be- 
tween. 281 
Chisels (see Cutting instruments) 
Cholecystectomy, 338 
Cholecystotomy, 338 
Choledochotomy. 338 
Cholelithiasis, 394 
Chromatin, 9 
Chromoplasm. 9 
Chronic diseas* . 
Cicatrizati< 
Cigarette drain-. 271 
Circulation, collateral 



INDEX 



407 



Clamping instruments, 283, 284 
haemostatic clamps, 284 
Halsted's clamp, 284 
Halsted's mosquito clamp, 284 
Kelly's clamp, 284 
Kocher's clamp, 294 
Ochsner's clamp, 284 
Pean's clamp, 284 
Tait's clamp, 284 
von Blunk's clamp, 284 
hemorrhoidal clamp (Kelsey's), 

283 
intestinal clamps, 284 
Kocher's, 284 
Wright's, 284 
Pean's pedicle clamp, 284 
stomach clamp ( Mayo-Rob- 
son's), 284 
Classification of symptoms, 57 
Claudius method of sterilizing cat- 
gut, 270 
Clavicle, fractures of, first aid in, 

361 
Clean wound, 34 
Cleft palate, 89, 377 
Cleveland ligature carrier, 291 
Clinical diagnosis, 59 

surgery, 82 
Clotting of blood, 67 
Club foot, 379 
Coaptation splints, 135 
Cold to control hemorrhage, 367 

uses of, 203 
Collar bone, fractures of, first aid in, 

361 
Collateral circulation, 67, 382 
Collins's uterine-holding forceps, 285 
Colloid degenerations, 81 
Colon bacillus, 48, 398 
Color in colonies of bacteria, 20 
Comfort of patient, measures for, 201 
Comminuted fractures, 382 
Compensatory changes, 66 
Complication, 56 
Compound fractures, 360, 382 



Compresses, 272 
Concealed hemorrhage, 382 
Congenital defects, 378 

deformities, 377 
Congestion, active and passive, 148 
Connective-tissue cells, 15, 70, 71 
Constitutional symptoms, 57 
Constructive tissue changes, 79 
Contact infection, 262 
Continuity of cell life, 13 
Continuous bath, 386 

irrigation in infected wounds, 

149 
proctoclysis, 146 
Contused wound, 34 
Costume, operating-room, 256 
Cotton, 260 

absorbent, 260 
Cranial set, instruments for, 330, 

331, 332 
Craniotomy, steps in, 337 
Crepe lisse, 273 
Crepitus, 383 
Crinoline bandage, 112 
Cubic centimetre, 26 

English equivalent of, 171 
Curettage set, uterine, instruments 

for, 329, 330 
Curettes (see Cutting instruments), 

280, 283 
Cutting instruments, 278 to 283 
bone-cutting forceps, 281 to 283 
Darby's rongeur forceps, 281 
Gluck's rib shears, 281 
Liston's bone-cutting forceps, 

281 
Luer's rongeur forceps, 281 
Velpeau's bone cutters, 281 
bone drills, 279, 280, 330, 332 
burrs, 279, 330 
Hamilton's bone drill, 280 
Hudson's cranial set, 330 
chisels and gouges, 281 
Brun's gouge, 281 
McEwen's chisel, 281 



106 



INDEX 



Cntting nrtruBents 

- > - la 1 1 . _ goa 
Me Ewer, 'a ^ _ 281 

ne 281 
Schwartze's chisel and gouge. 
281 
cur-:-:-- 28 

Blake a cure" - 281 
Buck - 

Luer's em c Cfc c 281 
Martin's anrettc 28 
placenta raretie 28 
rinsing i " Berlin 
28 
- 

El 28 
Thomas'- U 28 

Tolkmanr - - ~ ~ - 28 

knives, 278 271 

amputating knives _ ' 

bisto: - 278 271 

Catling amputating knife. 

_■ 
Listen's amputating knife. 

22 
seal; - 278 21 
: 

rd trephines. 
282 283, 332 

» - nieal trephine. 
28 
Gait's conical trephine. 28 
282 
- - - 282 

metacarpal u 282 

Wnd] - - 
- - t 278 23 

F.mm-t'> uter - - - _" 
- -.27 
Littauer '- ml ----_' 
Mayo's disseo* - - - - _ " 
-r, and du! 
.- 
umbilical - - - 27 



Cyan: — _ I 
Cyst of ovary. 4 I 
.--: k : :n- 
r_ 188 

- -" . n protoze; 28 
ban 

D 
Darby's rongeur forceps. 2 8 '. 
Defects 

oal . . - '_ - 
■ nitaJ 178 
Defer ees . ins : nfe v 
ities. ac-quirec. 
congenital 
Degeneration. 51 

Depii: ::rmula foot I7i 

- - . _ 128 

Desrra:-/ s tisa 

I eVID isefa b -; I 

Diagr :»> 18 

accidental injuries. 
Diarrhoea. - - - 28 
Diei n surgical aea, 2 21 21i 

Trtial diagn - - 
Dilatation and _ :>f uterus, 

- ps in. 341 
Dilate i - _ _ _ _ - - Auxil- 
iary instrum-: - 
Diphtheria bacilli. 20. 31 
Diploc 

- _ _ _ aec Auxiliary 

si 
i I - stepe 

Disa - 
■rate 

and health. 1»> 
cane - 
chr 
fm 57, 82 

organic. 
- ' 
sp«- 



INDEX 



409 



Dislocations, 382, 383 
Dispensary, gynaecological, arrange- 
ment of, 351 

draping of patient for exam- 
ination in, 355 

drugs, solutions, etc., in, 355 

examining and treatment room, 
352 

instruments in, 355 

preparation for examination in, 
354 

records in, 351 
Dissecting set, instruments for, 323, 

324, 327 
Dissectors, 292, 293 ( see Auxiliary 

instruments ) 
Dorsal position, 103 

splint of the arm, 135 
Dorsosacral position, 103, 107 
Double-current catheter, 294 
Douche, vaginal, technic of, 154 
Doyen's retractor, 287 

tissue-holding forceps, 285 
Drainage, 36, 44 

of abscesses, 386 

of bile, observation of, after 
gall-stone operations, 195, 394 
Drains, 270 
Draping of patient for examination, 

355 
Dress, operating-room, 256 
Dressed tube drains, 270 
Dressing, application of first, 321 

cart or carriage, 157 

forceps, 285 

of burns, 384 

room (surgeon's), 246 

room (ward), 156 

sterilizer, 248 
Dressings, attention to, 210 

care of perineal, 155 

drums for sterile, 254 

for wound, 271 

for wounds, materials for, 262 

observation of, 141, 191, 210 



Dressings, supplies, 159 

wet, 150, 204, 386 
Drills (see Bone drills), 279, 280, 

330, 332 
Drugs in gynoeco logical dispensary, 
355 

in operating room, 259 

pure, solutions from, 178 

styptic and astringent, in 
hemorrhage, 367 
Drums for sterile dressings, 254 
Dry gangrene, 389 

treatment of burns, 151 
Duodenum, ulcer of, 390 
Dysentery, 28 

E 
Ear, bleeding from, 383 
Ecchymosis, 381 

Edebohl's vaginal speculum, 288 
Efficiency, 235, 236, 243, 244 
Ehrlich's side-chain theory, 76 
Elbow-joint, fractures near, first aid 

in, 361 
Elevated dorsosacral position, 104 
Emergencies, 356 et seq. 
Emmet's ligature carrier, 291 

ovarian trocar and cannula, 294 

scissors, uterine, 279 

uterine dressing forceps, 285 
Empirical treatment, 59 
Emphysema, 50, 194, 381 
Endometritis, 400 
Endothelioma, 388 
Enema, method of administration of, 
142 

formulas for, 176 

varieties of, 144, 145 
Enteroptosis, 89 
Enuresis, 228 
Environment, 12 
Enzymes, 73 

Epithelial cells, 15, 44, 71 
Epithelioma, 388 

Epitome of surgical conditions, 377 
et seq. 



410 



INDEX 



Epitome of gynaecological conditions. 

394 et seq. 
Erect position, 106 
Erysipelas. 47, 385 
Esmarch bandage. 25S 
Etherizing room. 246 
Etiology.. 56 
Evacuators. 293. 294. 295 (see 

Auxiliary instrument? 
Excision. 94 

Exciting causes of disease, 56 
Excretion by cells, 10 
Exophthalmic goitre, 78, 389 
Exploratory operation, 94 
Exploring needles, 294 
Exposing instruments. 284 to 289 
retractor-. 2-4. 2-7. 289 

Doyen's abdominal retractor, 

287 
Ereer's nasal retractor, 2S6 
Halsted*s retractors. 286 
Jackson's hysterectomy re- 
tractor. 2-7 
Kelly's abdominal retractor, 

286, 2-7 
Langenbeck's retractor, 286, 

287 
Richardson's retractor, 2S6 
sharp hook retractors. 286 
Simon's sharp hook retractor, 

286 
Simpson-Mayo self-retaining 

retractor. 2-7 
Volkmann's sharp hook re- 
tractor. 286 
Young's prostatic retractor, 

287 
Young's vesical retractor, 287 
specula. 288. 

y'.- vaginal speculum, 288 
Acvard'a vaginal speculum, 

288 
Bodenhamers rectal specu- 
lum. 289 
Caro's urethra] speculum, 288 



Edebohl's vaginal speculum. 

288 
Ferguson's vaginal speculum, 

288 
Graves's vaginal speculum, 

288 
Halsted's rectal speculum, 28S 
Kelly's rectal speculum. 288 

urethral speculum, 25S 
Mathieu's rectal speculum, 

2-- 
Xelson's vaginal speculum. 

288 
Pratt's sigmoid speculum. 2^5 

urethral speculum. 2S5 
Bims'a vaginal speculum. 2SS 
Exstrophy of bladder, 378 
Extension (Buck's), apparatus for. 

138 
Extensive dissecting set, instru- 
ments for. 327 
Extremities, bandages of, 125 
Exudate, inflammatory, 42 

F 
Faeces, bacteria in. 2-> 
Falling of the womb | see Prolapse of 

uterus) 
Fats. 81 

Fatty degenerations. 81 
Feeding in hare-lip and cleft-palate 
cases, 378 
of surgical patients. 209 
Feelings, as symptoms. 197 
Felt splints, 135 
Female catheter. 294 
Ferguson's lion- jawed forceps. 285 
Fermentation. 5 
Ferments. 73 

. r.7. 61, »',4 
Septic, 41 
traumatic. 38 
Fibrinous exudate, 42 
Fibroid tumor of uterus. 401 
Fibroma. 388 
uteri. 401 



INDEX 



411 



Filterable viruses, 23 
First aid by nurse in accidents, 356 
et seq. 

intention, healing by, 7, 71 
Fissure in ano, instruments for, 329 
Fistula, intestinal, 206 
Fixation, 110, 139, 140 
Flannel bandage, 113 
Flaps in operative incision, 35 

osteoplastic, 36 
Fluffs, 271 
Focal symptoms, 57 
Foerster's forceps, 284 

sponge or dressing forceps, 285 
Food, baceria in, 27 

in surgical cases, 207 
Foot-drop, avoidance of, 203 
Forceps, 284, 285 (see Holding in- 
struments ) 

bone-cutting, 281, 283 (see Cut- 
ting instruments) 
Forearm, fractures of, first aid in, 

360 
Foreign bodies, 89, 380 

left in abdominal cavity, 380 
Formalin vapor, articles to be ster- 
ilized by, 302 
Formulae, 174-176 

for antiseptic solutions, 175 

for depilatory powder, 178 

for enemata, 176 

for local anaesthesia, 175 

for ointments, 177 

for pastes, 177 

for saline solutions, 176 

for soap, 177 

for vaginal douches, 177 
Four- tailed bandage, 111 
Fowler's position, 150 
Fractional doses, general rules for, 

165 
Fractures, 382 

at base of skull, 383 

at elbow- joint, first aid, 351 

compound, 360 



Fractures, infection in compound, 5 
observation after dressing, 141 
of ankle, first aid in, 361, 363 
of arm, first aid in, 361 
of clavicle, first aid in, 361 
of forearm, first aid in, 360 
of jaw, first aid in, 362 
of knee, first aid in, 363 
of leg, first aid in, 361 
of ribs, first aid in, 363 
of shoulder, first aid in, 361 
of thigh, first aid in, 362 
of wrist, first aid in, 360 
permanent fixation of, 140 
simple, 360 

temporary fixation of, 139 
treatment of, 134 

Freer's retractor, 287 

Frost gangrene, 64 

Functional disease, 55, 56, 57, 72, 
82, 92 

G 

Gall-bladder set, instruments for, 

325, 326 
Gall-stone disease, 394 
Gall-stones, 92 
Gait's trephine, 280 
Gangrene, 7, 62, 64, 389 

frost, 64 

hospital, 7 
Gangrenous appendicitis, 391 
Gas bacillus, 50, 359 
Gauze, absorbent, 259 

bandage, 112 

for drains, 270 

medicated, 271 

rolls, 272 
General abdominal set, instruments 
for, 323, 324 

symptoms, 57 
Genito-urinary surgery, 93 
Genu-pectoral position, 105, 108 
Gigli's saw, 282 
Glover's needle, 289 



il2 



INDEX 



Gloves, rubber. 257 see Rubber 

/, : ■-- 
Gluek's rib she?.:-. 28] 

Goitre 

exophthalmic. 78, 389 
Gonococcus _ 

Gouges (see Cutting instruments) 
Gowns, operating, 257 
- ■:':--"._: 

Gramme. English equivalent of, 171 
Granulation, healing 
Graves T s disease. 78 

vaginal speculum, 288 
Green pus. bacillus or. 48 
Grooved director - - 

-: ■ -- r ■?.:::■:'. : 
Gutta-percha tissn 
Gynaecological examination, draping 

patient for, I 
Gynaecology 

H 
Habitual host. 31 

Haemostatic clamps, 284 ( see Clamp- 
ing instrumer::- 
Hagedorn needle 28 

needle holder. _ I 
Hagner's double-current catheter, 

- - 
Halsted. Dr. W. fi use of rub- 

ber gloves 
-Hagedorn needle. _ - 

is clamj . 
mosquito clamp. 284 
mouse-toothed forceps. 2 - 5 
rectal speculum, 288 
retractor 28 
Ham splint. 135 
Hamilton's bone drill, 280 
Handkerchiefs, gauze, for dres 

--• 
Hare-1 

Hazards, opera t " __ 

Head, bandages of. - - 

operations, steps in. 337 



Healin. 

by first intention. 7 . " I 
by granulation, "_ 
normal. 7. 16, 37, 69 
process, 16, 60 
Health and disease. 16 
Heat, to control hemorrhage. 367 

sterilization by, I 
Hegar's needle holder, 291 
Hematoma, 381 
Hemorrhage, arrest of. 36 

control in accident eases, 364 
from ear in fractures at- base of 

skull, 8 
from large vessels, immediate 

control o: 
from varicose vein-. 
heat and cold in. 367 
postoperative. 222 
varieties of. 3S1 
Hemorrhoid set. instruments for, 

-" 28 
Hepaticotomy, 

Heredity, effect on parasitism 
Hernia 

operation for radical cure of. 

step b 
- t, instruments for, 323 
Herniotomy. - 
Hey's - 

Hip-joint, injuries of, first aid in, 363 
Holden's bone-holding forceps. 285 
Holding instruments. 286 to 28 
forceps. 284 285 

Collins"* uterus-holding for- 
ceps. 28S 
Doyen's tissue-holding for- 
ceps. 285 
dressing a, 285 

Emmet's uterine dressing 

forceps, 285 
Ferguson's lion-jawed for- 
ceps. 28 
Foerster's sponge or dressing 
for*, pa, 285 



INDEX 



413 



Holding instruments 
forceps 

Foersters straight and curved 

holding forceps, 284 
Halsted's mouse- toothed for- 
ceps, 285 
Holden's bone-holding forceps, 

285 
Houze's tongue-holding for- 
ceps, 285 
Kelly-Murphy forceps, 284 
Pean's T-forceps, 284 
Richter's volsellum forceps, 

285 
Skene's volsellum forceps, 285 
straight sponge stick, 284 
Van Buren's sequestrum for- 
ceps, 285 
tenaculum, 285 
Hollow instruments, care of, 295 
Holmes, Dr. Oliver Wendell, 4 
Homoeothermism, 203 
Hook retractors, sharp, 286 
Horizontal recumbent position, 101 
Horsehair for sutures, 266 
Horseley's bone wax, 271 
Hospital, attitude of nurse towards, 
374 
gangrene, 7 
wadding, 260 
Host, habitual, 30 

and parasite, 25, 28, 29, 31 
relation of parasite to, 28 
Hot-air sterilizer, 247 
Hot fomentations, 386 

pack, 150 
Hot-water bottles, proper tempera- 
ture of, 64, 203 
Houze's tongue-holding forceps, 285 
Hudson's cranial set, 330 

trephine, 330 
Human body, bacteria in, 28 
Hunter, John, 3 
Hyaline degeneration, 81 
Hyperemia, 57 



Hyperesthesia, 57 
Hyperplasia, 78 
Hypertrophy, 56, QQ, 79 
Hypodermic injection, technic of, 151 
medication, fractional doses in, 
161 
fractional doses, general rules 

for, 165 
stock tablets in, 166 
table of fractional doses, 163 
needles, care of, 295 
Hypodermoclysis, 208 
supplies for, 160 
Hyposecretion, 78 
Hysterectomy, steps in, 341 

I 

Ileus, 393 

Implantation infection, 262 

Incised wound, 34 

Incision, 35, 94 

Incontinence of urine, 227 

Infantile paralysis, 379 

Infected cases, precautions in, 211 

wounds, 3, 34, 41 
Infection, 17, 90 

by air, 5, 26, 29, 33 

by carriers, 31 

by mouth spray, 33 

carriers of septic, 31, 45, 299 

contact, 262 

defences against, 72 

implantation, 262 

in compound fractures, 5 

in wounds, bacteria concerned 
in, 46 
fever in, 41 
modes of, 45 

modes of, 32 

of wounds, postoperative, 224 

septic, 91 

surgical, 385 
Inhibition of bacterial growth, 298 
Injuries, diagnosis of accidental, 363 

of hip-joint, first aid in, 363 



414 



INDEX 



Injuries of knee, first aid in, 363 
Inflammation, 67 

cardinal signs of, 42 
exudate in, 42 
Insomnia, 57 
Inspection, 58 
Instrument room, 246 
sterilizer, 251 
table, 254 
Instruments, care of, 295 

in gynaecological dispensary, 352 
selection of, 323 et seq. 
surgical, 278 

auxiliary, 290 (see Auxiliary 

instruments) 
clamping, 284 (see Clamping 

instruments) 
cutting, 278 (see Cutting in- 
struments) 
exposing, 289 (see Exposing 

instruments ) 
general classification of, 278 
holding, 283 (see Holding in- 
struments ) 
sewing, 289 (see Sewing in- 
struments ) 
Intercellular substances, 10, 15 
Interest in observation, 190 
Internal angular splint, 135 
Intestinal clamps, 284 

fistulae, irritating discharges 

from, 206 
needles, 289 
obstruction, 393 

postoperative, 223 
perforation, 391 
Intestine, carcinoma of, 391 
Intestines, bacteria in, 28 
Intravenous infusion, supplies for, 

160 
Intussusception, 89 
Iodine, 22 

in skin disinfection, 215, 305 
sterilization of catgut, 270 
Irrigating stand, 255 



Irrigation, continuous, in local in- 
fections, 149 
rectal, 145 
Irritability of cells, 11 

J 

Jackson's retractor, 287 
Jaundice, 194 

Jaw, fractures of, first aid in, 362 
Johns Hopkins Hospital, first use of 

rubber gloves at, 7 
Joints, acquired deformities of, 379 

congenital dislocations of, 379 

dislocations of, 382, 383 

first aid in injuries of, 363 

fixation of, 110, 117 

fractures near, 383 

septic infection in, 387 

tuberculosis of, 388 
K 
Kangaroo tendon, 264, 270 
Kelly-Murphy forceps, 284 
Kelly's clamp, 284 

needles, 289 

pad, 258 

substitute for, 347 

rectal speculum, 288 

retractor, 287 

urethral dilator, 294 
Kelsey's hemorrhoidal clamp, 284 
Kernig's sign, 58 
Kidney set, instruments for, 325 
Knee chest, position, 105, 108 

fractures of, first aid in, 363 

injuries of, first aid in, 363 
Knives (see Cutting instruments), 
279 

care of, in sterilizing, 295, 302 
Knock-knees, 379 
Knowledge in observation, 190 
Koch, Robert, 6 
Kocher's clamp, 284 

intestinal clamp, 284 
Kronig's method of sterilizing cat- 
gut, 269 



INDEX 



415 



Laboratory, clinical, 58 
Lacerated wound, 34 
Laceration of the perineum, 397 

of uterine cervix, 397 
Lane plates, 271 
Langenbeck's retractor, 287 
Laparotomy packers, 263 
sheet, 257 
sponges, 263 
Laryngology, 93 
Lateral prone position, 105 
Leg fractures, first aid in, 361 
Lesion, 56 

Lesions of trauma, 381 
Leucocytes, 42, 68, 72, 76 
Ligature carriers (see Sewing in- 
struments ) 
Ligatures, 266 
Linear measure, 169 
Linen net, celloidin, for skin grafts, 

273 
Lipoma, 388 
Liquid measure (Apothecaries'), 170 

(metric), 170, 171 
Lister, Joseph, 4, 5, 6, 7, 95 
Lister's bandage scissors, 279 

needle, 289 
Liston's amputating knife, 279 

bone-cutting forceps, 281 
Lithotomy position, 103, 107 
posts, substitutes for, 347 
Litre, 170 

Littauer's scissors, 279 
Local anesthesia, formulae for, 175 

symptoms, 57 
Localizing symptoms, 57 
Lockjaw, 49 
Long side T-splint, 135 
Luer's curette, 280 

rongeur forceps, 281 
Lues (see Syphilis) 
Lymphangitis, 386 



M 

Major operation, 94 

Male catheter, 294 

Malformations, 377 

Malignant tumors, 24, 80, 388, 391, 

402 
Malta fever, 30 
Many-celled organisms, 13 
Marshall-Hall method of artificial 

respiration, 317 
Martin's bandage, 258 

curette, 280 
Mask, operating, 256 
Massachusetts General Hospital dis- 
sector, 292 
Mathieu's needle-holder, 291 

rectal speculum, 288 
Mayo-Robson stomach clamp, 284 
Mayo-Simpson self-retaining retrac- 
tor, 287 
Mayo's scissors, 279 
McEwen's chisel, 281 

gouge, 281 

osteotome, 281 
Measure of volume, 170 
Measurements in observation, 198 
Measures of weight, 171 
Measuring glasses, 258 
Mechanical causes of disease, 62 

derangements, 63, 89 
Medical words, derivation, 83 

method of construction, 83, 84 
root-words, 84, 85 
prefixes, 86 
suffixes, 87 
Metacarpal saw, 282 
Metal splints, 135 
Metaplasia, 56 

Metre, English equivalent of, 169 
Metric system, 169 
Mickulicz pads, 263 
Micrococci, 22, 26 
Micrococcus gonorrhoeae, 52, 91 
Milk as source of infection, 28 
Minor operation, 94 



416 



INDEX 



Moist gangrene, 389 

heat, 386 
Moony 's ligature carrier, 291 
Morbidity, 96 
Morphine, administration of, 205 

and scopolamine, administra- 
tion of, 233 
Mortality, 96 

surgical, before Lister, 3 
Mortification, 389 
Mouth, bacteria in, 28 

spray, infection by, 33 
Movement of cells, 10 
Mucoid degeneration, 81 
Multiplication of bacteria, 19 
Murphy button, 271 

drip, 146 
Muscle cells, 15 
Muslin bandage, 112 
Myoma, 388 

N 

Nail cleaners, 256 
Nails, care of, 306 
Nausea, 57 

Neck, bandages of, 124 
Necrosis, 5Q, 80 

of bone, 387 
Needles (see Sewing instruments ) , 
289, 290 

aspirating, 294 

for arterial suture, 276 

hollow, care of, 295 
Needle-holders (see Sewing instru- 
ments), 291 
Nelson's vaginal speculum, 288 
Neoplasia, 57, 91 
Neoplasms, 79, 91, 388 
Nerve-cells, 15 
New-growths, 79, 91, 388 
Noble's needle-holder, 291 
Nomenclature, 83 et seq., 94 
Normal, definition of, 16, 60 

healing, 7, 37 
Nott's double-current catheter, 294 



Novocaine, 175, 233 
Nucleus, 9 

Nurse, administration of morphine 
by, 205 
assisting anaesthetist, 317 
in operating room, duties of, 

244, 316, 317, 318 
observation by, 189 et seq. 
part in anoci-association, 234 
personal attitude of, 372 et seq. 
to self, 375 

towards the hospital, 374 
towards the patient, 372 
towards the public, 375 
towards the surgeon, 373 
responsibility of surgical, 7, 8, 
95, 244 
Nutrireceptors of cell, 78 
Nutrition of cells, 10, 11 

O 
Objective symptoms, 57 
Obligation, surgical, 97 
Observation, 189 et seq. 

by nurse, purpose of, 189 
meaning of, 189 
measurements in, 198 
method in, 190 

quantitative judgments in, 198 
record of, 200 
scale of seven, 199 
Obstruction, intestinal, 393 
Ochsner's clamp, 284 

gall-bladder trocar and cannula, 
294 
(Edema, 61, 194, 381 
Ointments, formula^ for, 177 
Oozing from wound, 37, 115 
Open operation, 35 

treatment of burns, 151 
Operating gowns, 257 
Operating materials, 261 to 277 
celloidin linen net, 273 
classification of, 261 
crepe lisse, 273 
drains, 270 



INDEX 



417 



Operating materials, drums for 

dressings, 270 
for suturing arteries and 

veins, 276 
gauze for dressings, 271, 273 
gutta-percha tissue, 273 
ligatures, 266, 275 
materials to fix dressings, 273 
medicated gauze, 271 
method of assembling, 284 
packers, 263 
retractors, muslin, 264 
sponges, 262 
sutures, 264, 275 
unit package of, 275 
Operating room, arrangement of, 316 
dress, 256 
fixtures, 247 
furniture, 254 
in private house, 345 
nurse, responsibility of, 244 
nurses, duties of, 316 

un scrubbed nurse, 317 

instrument and suture 
nurse, 318 

sponge nurse, 318 
organization, 243 
personnel, 314 

anaesthetist, 314 

first assistant, 315 

second assistant, 315 

nurse in charge of instru- 
ments, 315 

nurse in charge of sponges, 
315 

unscrubbed nurse, 315 

operator, 315 

orderly, 244, 315 
preparation of, 31iJ, 313 
rooms connected with, 246 
supplies, 256 
temperature of, 320 
utensils, 255 
Operating table, 254 

in private house, 345 



Operating table, pad for, 255 
Operation, 3, 8, 34, 35 
bloodless, 35 

in private houses, 345 et seq. 
anaesthetic, choice and dan- 
gers of, 347 
artificial light, 346 
Kelly pad, substitute for, 

347 
lithotomy posts, substi- 
tutes for, 347 
room, choice of, 345 

preparation of, 345 
sterilization of instru- 
ments, water, etc., 347 
table, type and preparation 

of, 345 
utensils and supplies, 345 
necessary equipment for, 311 et 
seq. 
for the anaesthetist, 311,312 
for the operator and as- 
sistants, 312 
for the patient, 311 
for scrub nurse, 312 
for the unscrubbed nurse, 
312 
nomenclature of, 94 
open, 35 
plastic, 89 

preparation of nurse for, 313 
preparation of patient for, 213 
bowel function, 213 
diet, 213, 216 
field of operation, 214 
reparative, 89 

routine after treatment, 215 
minor procedures, 216 
administration of water, 216 
nourishment, 216 
routine treatment after, 271 
et seq. 
belts, binders and supports, 

221 
bladder function, 217 



418 



INDEX 



Operation, routine treatment after, 
bowel function, 219 
dressings, 220 
going home, 220 
opiates, 219 
sitting up, 220 

steps of, 35 

team work at, 244 

upon the extremities, steps in, 
342 et seq. 

upon the head, steps in, 337 

upon the trunk, steps in, 337 
Operative hazards, 95, 97, 229, 237 

steps, 336 et seq. 

surgery, 94 

wounds, 35 
Ophthalmology, 92 
Optimum temperature, 11 
Organic changes, 55 

disease, 56 

sensations, 196 
Organisms, many-celled, 14 

single and many-celled, 13 

single-celled, 13 
Organization in many-celled forms, 

14 
Orthopaedic surgery, 93 
Osteoma, 388 
Osteomyelitis, 386 

set, instruments for, 334, 335 
Osteotome, 281 

and chisel, difference between, 281 

McEwen's, 281 
Otology, 93 
Ovarian cyst, 401 
Oxidation in cells, 10 



Pack, hot wet, 150 
Packers, laparotomy, 263 
Packing, uterine, 160, 272 

vaginal, 160, 272 

wounds, 366 
Pad for operating tal>l<\ 255 

Kelly, 258 



Pads, 271 
Pain, 37, 196 

inflammatory, 196 

localization of, 196 

measures for relief of, 204-206 

mental attitude toward, 207 

referred, 196 
Palliative operation, 94 

treatment, 59 
Pallor, 194 
Palmar splint, 135 
Palmer's cervical dilator, 292 
Palpation, 58 

Panhysterectomy, steps in, 341 
Paradoxical incontinence of urine, 

227 
Parasite, relation to host of, 28 
Parasitic organisms, 23, 25, 29 
Passive congestion, 148 
Paste, bismuth, 150 

formulae for, 177 

Unna's, 150 
Pasteboard splints, 135 
Pasteur, Louis, 4 
Pathogenic bacteria, 20 
Pathognomonic symptoms,. 57 
Pathological anatomy, 60 

changes, meaning of, 60 

diagnosis, 59 

histology, 60 

physiology, 60 
Pathology, 59 

surgical, 60 
Patient, anaesthetized, care of, 317, 
319 

attitude of nurse towards, 372 

care of, after operation, 322 

comfort and well-being of, 201 

draping of, for examination, 355 

preparationof, for operation,213 
Pean's clamp, 284 

pedicle clamp, 284 

T-forceps, 284 
Peaslee's ligature carrier, 291 



INDEX 



419 



Pelvic abscess, 400 

set, instruments for, 325, 320 
Penetrating wound, 34, 382 
Percussion, 58 
Perforation of intestine, 391 
Perineal dressings, care of, 155 

set, instruments for, 331 
Perineorrhaphy, steps in, 342 
Periosteal elevators, 292 
Peritonitis, 64, 91, 224 
suppurative, 391 
tuberculous, 393 
Personal attitude of nurse, 372 
Phagocytosis, 72, 76 
Phlegmon, 385 
Physical causes of disease, 63 

signs, 57 
Physiological salt solutions, for- 
mulae for, 176 
intravenous administra- 
tion of, supplies for. 160 
supplies for subcutane- 
ous administration of, 
160 
Pillow splint, 361 
Placental curette, 280 
Plaster, adhesive, 260 (see Adhesive 

plaster) 
Plaster-of-Paris bandages and casts, 
130 
method of making, 133 
Plastic operation, 89, 94 
Plating or wiring set, instruments 

for, 335 
Pleural cavity, infection in, 387 
Pneumococcus, 31 
Pneumonia, 31 

postoperative, 226, 227 
Poecilothermism, 203 
Poison, 65 
Poisoned wound, 34 
Poliomyelitis, anterior, 379 
Positions ( see Postures ) 
Fowler's, 150 
in bed, 202 



Posterior leg splint, 135 
Postures, 101 

dorsal, 103 

dorsosacral, 103, 107 

elevated dorsosacral 104 

erect, 106 

Fowler's, 150 

genu-pectoral, 105, 108 

horizontal recumbent, 101 

knee-chest, 105, 108 

lateral prone, 105 

lithotomy, 103, 107 

reversed Trendelenburg, 102 

Sims's, 105 

Trendelenburg, 101, 107 
Pratt-Hank's cervical dilator, 292 
Pratt's rectal bougie, 294 

sigmoid speculum, 288 

urethral speculum, 288 
Precautions in infected cases, 211 
Precursory symptom, 57 
Predisposing causes of disease, 56 
Prefixes, 86 

Premonitory symptoms, 57 
Preparation of patient for operation, 

213 
Pressure, bandaging for, 116 

effects of, 62, 211 

from bandages, 117, 210 
Presumptive diagnosis, 59 
Probe, silver, 292 
Probe-pointed grooved director, 292 
Proctoclysis, 208 

continuous, 146 
Prodromal symptoms, 57 
Prolapse of the uterus, 396 
Protective, 273 
Proteids, 81 
Protozoa, 22 
Provisional, 59 
Public, attitude of nurse towards, 

375 
Pus, 42 

Putrefaction, 5 
Pyaemia, 45, 226 
Pyosalpinx, 400 



420 



INDEX 



Quantitative judgments, 198 
Quantity, estimations of, 199 
Quinine and urea hydrochloride, 
175, 233 

R 
Rack for abdominal pads, 255 
Eadical operation, 94 

treatment, 59 
Radium, 63, 402 
Rational treatment, 59 
Reaction to stimuli, 12, 14, 15, 56, 

58, 60, 78 
Receptors of cell, 78 
Records, 180 

in gynaecological dispensary, 351 

of observations by the nurse, 200 
Recovery room, 246 
Rectal irrigation, 145 

plug, 273 

set, instruments for, 9, 327 

tubes, 258 
Red corpuscles of blood, 75 
Referred pain, 196 
Regeneration, 56 
Remedial measures, 142 
Reparative operation, 89 
Reproduction of cells, 10 
Resection, 94 

of rectum, instruments for, 329 

of rib, steps in, 338 

set, instruments for, 335 
Rest in treatment of trauma, 384 
Resting stage in single-celled organ- 
isms, 11, 20, 22 
Restlessness, 57 
Retention of urine, 227 
Retractors, 264, 284, 287, 289 (see 

Exposing instruments) 
Retroflexion of the uterus, 396 
Retroversion of the uterus, 395 
Reverdin's ligature carrier, 291 

method of sterilizing catgut, 269 
Reversed Trendelenburg position, 
101, 107 



Rhachitis, 379 
Rhinology, 93 
Rib shears, 281 
Ribs, fractures of, 363 
Richardson's rectractor, 387 
Richter's needle holder, 291 
volsellum forceps, 285 
Rickets, 379 

Right-angled elbow splint, 135 
Risks, operative, 95, 97, 229, 237 
Rongeur bone-cutting forceps, 281 
Room, examining and treatment, in 
gynaecological dispensary, 352 
in private house, for operation, 

345 
operating (see Operating room) 
Root-words, 84, 85 
Routine treatment after operation, 

215 
Rubber apron, 256 

articles, care of, 258 
drainage tubes, 270 
gloves, 7, 257 
first use of, 7 
method of mending, 257 
method of putting on, 304 
method of sterilizing, 302 
tourniquet, 258 
tubing, 258 
Rupture, 393 

of bladder, 383 



Salpingitis, 400 

Salpingo-oophoritis, 400 

Salt solutions, formulae for, 176 

intravenous administration of, 
160 

subcutaneous administration 
of, 160 
Saprsemia, 224 
Saprophytic bacteria, 20 
Sarcoma, 80, 388 
Satterlee's saw, 282 



INDEX 



421 



Saws, 279, 282, 283, 332 
Gigli's wire saw, 282 
Hey's skull saw, 282 
metacarpal saw, 282 
S'atterlee's saw, 282 
Windler's saw, 332 
Scale of seven, 199 
Scalpels, 278, 279 
Scar, 41 

Searching instruments (see Auxil- 
iary instruments), 292, 293 
Schleich's marble dust soap, 177, 256 
Schwartze's chisel, 281 

gouge, 281 
Scissors (see Cutting instruments) 
Scoliosis, 379 
Scopolamine, 233 
Scultetus bandage, 111, 274 
Secretion of cells, 10 
Sensations, organic, 196 
Sepsis, 35 
Septic diseases, 385 
infections, 91 
in joints, 389 
in serous cavities, 387 
men and animals as carriers 
of, 31, 45, 299 
wound, 34 

infection, bacteria concerned 

in, 45 
infections, sources and modes 
of, 45 
Septicaemia, 45, 225 
Septicopyemia, 45 
Sequelae, 56 

Serous cavities of body, 3 
Serum, antitetanic, 359 
Seven, scale of, 199 
Sewing instruments, 289, 290, 291 
ligature and suture carriers, 291 
aneurism needle, 291 
Carsten's, 291 
Cleveland, 291 
Emmet's, 291 
Moony 's, 291 



Peaslee's, 291 
Reverdin's, 291 
Whitehead's staphylor- 
rhaphy, 291 
needles, 289, 290 

Emmet's half -curved, 289 
Glover's needle, 289 
Halsted-Hagedorn, 289 
intestinal, 289 
Kelly's, 289 
Lister's, 289 

surgeon's half-curved, 289 
surgeon's full-curved, 289 
triangular point needle, 289 
needle-holders, 290, 291 
Hagedorn's, 291 
Hegar's, 291 
Mathieu's, 291 
Noble's, 291 
Richter's, 291 
Shafer method of artificial respira- 
tion, 369 
Sharp hook retractor, 286 
Sheet, laparotomy, 257 
Shock in accident cases, 371 

postoperative, 222 
Shoes, operating, 257 
Shoulder cap, 135 

fractures, first aid in, 361 
Side-chain theory, Ehrlich's, 77 
Signs, 58 

Graefe's, 58 

Kernig's, 58 

physical, 57 

Silk bolting cloth, 273 

Silkworm-gut, 266 

Silver foil, 260, 273 

probe, 292 
Silvester method of artificial respi- 
ration, 369 
Sincerity in anoci-association, 235, 

236 
Single-celled organisms, 13 
Simon's retractor, 286 
Simple fractures, 360, 382 



422 



INDEX 



Sims's curette, 280 

position, 105 

uterine sound, 292 

vaginal speculum, 288 
Skene's self-retaining catheter, 294 

volsellum forceps, 285 
Skin, disinfection of, 298, 299, 305 
Sleeping sickness, 30 
Snake bite, 34 
Soap, 256 

formula for, 177 
Solution of continuity, 381 
Solutions, 173, 178 

basins for, 254 

in gynaecological dispensary, 355 

preparation of, 173, 178 
Sound, urethral, 294 

uterine, 292 
Specialism, surgical, 92 
Specialization of cell activities, 12 
Specific disease, 56 

treatment, 59 
Specula, 288, 289 (see Exposing in- 
struments ) 
Spina bifida, 378 
Spirilla, 18 
Splints, blanket, 361 

improvised in first aid, 360 

material for fastening, 137 

materials for, 260 

padding of, 136 

pillow, 361 

pressure by, 62, 211 
Sponge forceps, 284 
Sponges, gauze, 36, 262 
Spoon curette, 280 
Spores, 11, 20, 22 
Spray of carbolic solution, 5 
Stability in cell life, 14 
Staining cell and nucleus, 9 
Staphylococcus pyogenes albus, 46, 
386, 398 

pyogenes aureus, 46 
Steam, articles to be sterilized by, 
301 



Steam, sterilization by, 300 

sterilizer, 248 

under pressure, sterilization by, 
7, 301 
Stenosis of vagina, 395 
Sterilization, by heat, 300 

apparatus for, 247 et seq. 

by steam under pressure, 7, 248, 
301 
apparatus for, 248, 250 

definition of, 298 

in operating room, 248 to 253, 
301 

in private house, 345, 347 
Sterilized outfit, assembling and 

handling, 302 
Sterilizers, 247 et seq. 

dressing, 248 

for steam under pressure, 248 

hot-air, 247 

instrument, 251 

utensil, 251 

water, 253 
Sterilizing cutting instruments, 295 

room, 246 
Stick sponge forceps, 284 
Stimulus, 11, 12, 14, 15, 38, 56, 60, 

64, 70, 78 
Stomach, acute dilatation of, 223 

carcinoma of, 391 

and intestine set, instruments 
for, 325 

bacteria in, 28 

clamps, 284 

tubes, 258 

ulcer of, 390 
Stone searcher, 292 
Stones in bladder, etc., 81 
Stools, observation and record of, 

195, 394 
Strangulated hernia, 394 
Streptococcus infection of throat, 28 

pyogenes, 46, 386, 398 
Stretcher, wheel, 254 
Stricture of the oesophagus, 320 



INDEX 



423 



Struma, 389 

Styptic drugs in hemorrhage, 367 

Subcutaneous wound, 34 

Subjective symptoms 57, 196 

Suffixes, 87 

Suggestion in anaesthesia, 239, 240 

Super-technic, 307 

Supply room, 246 

Supports, abdominal, postoperative, 

221 
Suppression of urine, 228 
Suppurating wound, 34 
Suppuration in wounds, 42 
Suppurative peritonitis, 391 
Surgeon, attitude of nurse towards, 

373 
Surgeons' half- and full-curved 

needles, 289 
Surgery, clinical, 82 

definition of, 89 
Surgical obligation, 97 

infections, 385 

pathology, 60 

specialism, 92 
Suture carriers (see Sewing instru- 
ments ) 
Sutures, 264 

absorbable, 265 

non-absorbable, 265 
Suturing of arteries and veins, 276 
Swabs (see Sponges) 
Swelling of limb below bandage, 117 
Symptomatic treatment, 59 
Symptoms, 57 

classification of, 57 

constitutional, 57 

definitions, 57, 193, 196 

focal, 57 

index, 193 

local, 57 

objective, 57, 193 

observation of, 192 

of trauma, 383 

pathognomonic, 57 

premonitory, 57 



requiring that the surgeon be 
summoned, 192 

significance of, 191 

subjective, 57, 196 
Syndrome, 57 
Syphilis, organism of, 51 

T 
Table of fractional doses, 163 

operating, pad for, 255 
in private house, 345 
Tait's clamp, 284 

ovarian trocar, 294 
Tampons, 272 
T-bandage, 111, 274 
Team work at operation, 244 
Technic, anoci-association, 232 

aseptic, 8, 299 et seq. 

definition of, 296 

surgical, three divisions of, 297 
Temperature, effect on cell life, 11 

of operating room, 320 
Tenaculum, 285 
Tenotomy knives, 279 
Tetanus, 78 

antitetanic serum in prevention 
of, 359 

bacillus, 49, 359 
Thermal death point of bacteria, 298 

of human tissue cells, 64 
Thigh, fractures of, first aid in, 362 
Thirst after anaesthetic, 208 
Thomas's curette, 280 
Thompson's stone searcher, 292 
Thoracotomy, 338 
Thorax, bandages of, 125 
Threshold of stimulus, 12 
Throat, bacteria in, 28, 31 
Thrombosis of mesenteric artery, 

394 
Tissue changes, 79 

gutta-percha, 273 
Topical symptoms, 57 
Tourniquet, improvised, 366 

rubber, 258 
Towels, 257 



424 



IXDEX 



Toxins, 76 

Trachelorrhaphy set, instruments 
for, 331 

steps in, 342 
Transmission of infection, modes of, 

32 
Transplantation of tendons, 379 
Transportation of accident cases, 

363 
Transposition of tables of weights 

and measures, 172 
Trauma, 89, 381 
Traumatic fever, 38 
Treatment, 59 

active, 59 

definitions, 59 

empirical, 59 

expectant, 59 

of trauma, 384 

palliative. 59 

radical, 59 

rational, 59 

specific, 59 

symptomatic, 59 
Trendelenburg position, 101 
Trephines, 279, 280 (see Cutting 
instruments) 

DeVilbiss's, 280 

Gait's, 2S0 

Hudson's, 330 
Trephining, 3 

steps in, 337 
Treponema pallidum, 51 
Triangular bandage, 113 

point needle, 289 
Trocar and cannula, 294 

care of, 295 
Trunk, operations upon, steps in, 337 
Tube drains. 270 
Tubercle bacillus, 50, 91 
Tuberculosis, 28, 51, 387 

surgical, lesions of, 388 

surgical, treatment of, 388 
Tuberculous peritonitis, 393 
Tubing, rubber, 258 



Tubo-ovarian abscess, 400 
Tumors, 79, 91, 3S8 
Two-stage operation, 94 
Typhoid fever, 28, 31 

U 
Ulcer, 91 

of duodenum, 390 

of stomach, 390 
Ulcerative appendicitis, 391 
Umbilical scissor;, 279 
Unicellular organisms, 13 
Unknown invaders, 23 
Unna"s paste, 150 
Urethral sound, 294 
Urine, paradoxical incontinence of. 
228 

retention of, 207, 227 

retention with overflow, 227 

suppression of. 22-? 
Utensil sterilizer, 251 
Uterine packing, supplies for, 160 

packs, 210, 272 

sound, Sims' s. 292 
Uterus, cancer of. 402 

fibroid tumor of, 401 

prolapse of. 396 

retroflexion of, 396 

retroversion of. 395 



Vagina, atresia of, 395 
Vaginal douches, formulae for, 177 
technic of, 154 
packing, 272 

supplies for, 160 
packs, 210 
Vaginitis, 399 

Van Buren's sequestrum forceps, 2S5 
Varicose veins, 89 

hemorrhage from. 367 
Venous hemorrhage. 3S1 
Velpeau bandage. 127 

bone-cutting forceps, 281 
Verbal suggestion in anaesthesia, 
239, 240 



INDEX 



425 



Viruses, filterable, 23 
Volkmann's curette, 280 

retractor, 286 

sliding rest, 136, 140 
Volvulus, 89 
Vomiting, 57 
von Blunk's clamp, 284 
Vulvitis, 399 

W 

Wadding, hospital, 260 
Wale's rectal bougie, 294 
Water, absorption of, in the intes- 
tine, 208 
administration of, 207, 384, 386 

in infections, 208 
by mouth, when to be withheld, 

209 
necessary for cell life, 11 
sterilizers, 253 
Wathen's cervical dilator, 292 
Waxy degeneration, 81 , 
Webbing, 137 

Weiss's urethral dilator, 294 
Well-being of patient, measures for, 

201 
Wet dressings, 150, 204, 386 
Wheel stretcher, 254 
Whitehead's ligature carrier, 291 
Wick drains, 271 
Windler's saw, 332 
Wiring or plating set, instruments 
for, 335 



Wooden splints, 135 
Wounds, 3, 5, 7, 16, 34, 41 
accidental, 34 

first aid in, 357 
dressings for 271 
infected, 3, 5, 7, 16, 31, 34, 41, 
45, 299 
healing in, 44 
symptoms of, 43, 45 
infection of, bacteria concerned 
in, 46 
fever in, 41 
postoperative, 224 
materials for dressing, 262 
of special structures, 382 
operative, 35 

septic infection of, sources and 
modes, 45 
Wright's intestinal clamp, 284 
Wrist fractures, first aid in, 360 



X-ray, 63, 383, 402 



Young's retractor, prostatic, 287 
vesical, 287 



Zinc, carbonate, precipitated, 206 
oxide, 206 

ointment, 177 



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